RebelCard Reader Sign-Out Form

Requester Information
Event Information
Billing Information
Please provide the contact information for the person who authorizes purchase for your group or department. Billing information is for future use or in the event the reader is damaged.
Disclaimer
By entering your name in the field below, you agree to take full responsibility for the reader from the time you receive it until you return it. All readers must be returned on the business day following your event. If the reader is lost or damaged, you will be held financially responsible until you organization replaces the reader at the current rate (As of January 1, 2018 -- $1700). Your e-signature also indicates your understanding that the data you collect is governed by the Family Educational Rights and Privacy Act (FERPA). In compliance with the Act, data may be used for educational purposes only and will not be released to a 3rd party.