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Impaired Vision Goggles Checkout Form

1. The goggles must be returned to the DCCCA, Inc./SAFE Office.
2. Return the goggles by certified parcel service, i.e., Federal Express, UPS, etc. Insure the contents for the replacement value of $1000.
3. The individual/organization named on this loan agreement is responsible for damage to and/or loss of the contents. While the contents are in your possession, it is recommended that they are insured for their replacement value of $1000.

Your Contact Information

I have read this loan agreement and understand the requirements outlined. If there are any changes in my/the organization's plans, I will notify the OK SAFE Coordinator immediately. By typing your name in the space provided, and entering today's date, you are signing this agreement.

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