Equipment Checkout Form

First Name*

Last Name*

I received the following equipment from the University of Washington Math Science Upward Bound (UW STEMsub) Program for academic use:*

Laptop

Graphing Calculator

OtherOther

Make/Model: *

Serial Number:*

UW Tag Number:*

I am responsible for its safe use and return to the Math Science Upward Bound Program on or before the last day of the current academic school year. If equipment is not returned in good working order by this date, I may be charged for replacement cost.

Print Student Name*

Student Signature*

Clear

Date*

Print Parent Name*

Parent Signature

Clear

Date*

If you are human, leave this field blank.

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Fully funded by two five year grants from the U.S. Department of Education, Office of Federal TRIO Programs of $575,074 per year.
Math Science Upward Bound is a unit under the Office of Minority Affairs & Diversity, University of Washington