Teacher's / Homeschooler's Loan Request Form

Today's Date:
Date materials are to be ready for personal pickup (Please allow seven days):



Name:
School's name
(or homeschool):

School phone (with extension):

Home or Cell phone:
Email:
Preferred method of contact:
Email School phoneHome or Cell Phone
Age/grade level(s) of students (approximate):

Number of students (approximate):

Special needs, if any, of the student(s):
Reading level(s) of student(s):
Below Reading Level
At Reading Level
Above Reading Level

Subject(s) needed/Intended use (Teacher Use or Research, Student Use or Research, Readalouds, etc.):
Total number(s) of materials (Approximate):

Kinds of information and materials needed:
FictionNonfiction Picture BooksDVDs or VHS CDs

Titles of specific materials (if applicable):