UWG Teacher Quality Participant Materials Checkout Form

Applications of Energy-Related Core Ideas and Practices Across Middle and Secondary
Earth/Life/Environmental Sciences (AOEC)
Name __________________________________________________

Date ______________________________

Your Address ____________________________________________

____________________________________________
Your Phone No. ____________________________________
School Name ____________________________________________

School System Name _________________

School Address _________________________________________

_________________________________________
School Phone No. ___________________________________

By signing below, I affirm that I understand the following:

That the items I am requesting are the property of the University of West Georgia and
must be returned by the agreed upon date;
Items checked out are for use only at my school by me and/or my students;
Items must be returned with all related literature and supporting items (cords, etc.)
in the condition in which the items were received. In cases of negligence, restitution
may be required.
It is my responsibility to read, prior to use, all directions with the items or in
documents regarding use, cleaning, storage, etc. of the items;
It is my responsibility to establish and enforce proper safety practices and to closely
supervise students who use these items.
It is my responsibility to properly secure the items when not in use to prevent
unsupervised use by students and/or theft of the items.
Any concerns about use, damage, theft, etc. must be reported promptly to the AOEC
Project Leaders.

Your signature __________________________________________

Date _______________________

The following page has the list of items available for check out and the number of those
available. Not all of the items used in the summer program are available on this list. Some of those
were not purchased with grant funds and others due to intended use, shipping hazards, etc. are not
available.
When you submit the form, the date of the email will be used to determine priority if more than
one person requests items of limited availability. Items can only be checked out and in on/at the
designated dates and locations. UWG has no provision for delivery/pick up by any other means. It is
possible to arrange for you to pick up and return available items in the Callaway Building on the UWG
Carrollton campus.
_____________________________________________________________________________________
DO NOT WRITE IN THIS SPACE RESERVED FOR AOEC PROJECT PERSONNEL
AOEC
Initials
Date of submitted check out form (on
email)
Name of person assembling items for

checkout
Date of transfer of items to person
checking these out
Date and location for return of
checked out items
Date of return of checked out items
AOEC PARTICIPANT ITEMS CHECKOUT REQUEST FORM
NAME OF PERSON SUBMITTING THE REQUEST
______________________________________________________
(ALL ITEMS ON THE INFORMATION PAGE MUST BE COMPLETE BEFORE CHECKOUT REQUEST
WILL BE PROCESSED.
Item #
(UWG
List)

Item Name (UWG List)

Number
Requested

Number
Provided

Comments