Form 04190 – Fill Out and Use This PDF

EQUIPMENT RELEASE FORM

As part of the Digital Divide Program, The School Board of Broward County, Florida “DONOR” releases equipment ownership and any liability derived from its future household use (such as parts or software break-down) to the transferee “RECIPIENT”. RECIPIENT acknowledges that he/she received the technology equipment as indicated on this form--with a functioning operating system and installed educational software--from the DONOR at no cost to him/her for his/her household use.

RECIPIENT, please complete the following information. (Note: Information on school(s) and grade(s) attending for all children in the family are also required.)

	First Name	Middle Initial		Last Name
Street Address			Apt. #	City
State	Zip Code	County		Home Telephone Number

Please check this box if you are a School Board of Broward County, Florida employee: 

CHILD’S NAME AND LAST NAME

SCHOOL CURRENTLY ATTENDING GRADE

1._________________________________ ___________________________________ ______

2._________________________________ ___________________________________ ______

3._________________________________ ___________________________________ ______

DONOR, please complete the following information:

Item –Quantity _____
Equipment Description:
Manufacturer
Model:		Serial Number:
Peripherals:
Mouse 	Keyboard  Computer Cables  Speakers 

Other (Please describe) __________________________________________________________

cc: RECIPIENT	Page 1 of 2	Form 04190
Original to Digital Divide File		Revised 11/7/2008

Software (Please list all software installed, including that for the operating system):

DISCLAIMER: Central Processing Units released for home use by Donor are operational and in good working condition. Level of technological capability depends on the unit’s hardware specifications. All central processing units donated to the public were re-initialized (low-level initialization) and had a clean operating system reinstalled. RECIPIENT is not entitled to any software upgrades. Software installed is provided “AS IS” and SBBC is not responsible for any faults found within. No additional warranties to these items--either written or implied—exist or may be made by The School Board of Broward County, Florida or its employees.

RECIPIENT Acknowledgement:

I acknowledge that I received all technology equipment as indicated on this form. I understand that The School Board of Broward County, Florida through the Digital Divide Program, released ownership of the equipment to me, free of charge, and that if the equipment (hardware/software) needs service at a future date, the cost for the item(s) transportation, service, and repair will be at my own expense.

____________________________________________________	_______________________
RECIPIENT’s Signature	Date
(Child may complete/sign this form if over 18 years of age.)

FOR SBBC USE ONLY.

To be completed by person at school/site distributing the equipment to eligible RECIPIENT.

____________________________	______________________	________________________
Employee Name	Employee Title	Employee’s SBBC Number
____________________________	______________________
Employee’s Signature	Date

cc: RECIPIENT	Page 2 of 2	Form 04190
Original to Digital Divide File		Revised 11/7/2008