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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 State Apt. Zip Code County City 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. 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 Original to Digital Divide File Page 1 of 2 Form 04190 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 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 Child may complete/sign this form if over 18 years of age. Date FOR SBBC USE ONLY. To be completed by person at school/site distributing the equipment to eligible RECIPIENT. Employee Name Employee Title Employee s Signature Employee s SBBC Number. 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 State Apt. 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 State Apt. Zip Code County City 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..

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