SCHOOL YEAR: _________ GRADE_______
HOME ROOM (Elementary only)___________________
Northwest Community Schools Technology Handbook 2020-2021 
19
Attachment B - page 2
Northwest Community School District
The Direction of Greatness 
Oponal Electronic Device Insurance Protecon Plan
Child’s Name
GRADE:
Parent/Guardian
Name
Mailing Address
City, State, Zip
Home Phone:
Cell Phone:
I WILL parcipate in the oponal Northwest Community School District’s Electronic Device Accident
Protecon Plan. I agree to the provisions outlined in the policy terms and understand that:
● Enrollment in this program is oponal.
● The policy only covers the school issued electronic device and does not cover the charger or case.
● This policy does not cover cosmec damage that does not impair the use of the electronic device;
including, but not limited to: scratches, dents, and broken plasc parts or connecon ports.
● Damage as a result of a violaon of the Electronic Device User Agreement is not covered; including, but
is not limited to: dishonest, fraudulent, intenonal, negligent, or criminal acts.
● Damage to the device is sll the responsibility of the individual employee or student.
● Liability is limited to the replacement/repair of the device; no addional liability is implied or assumed.
● Opening the casing of the device to expose its internal components or hacking the operang system
voids warranes and is not covered by this policy. Physically tampering with or hacking the operang
system in an aempt to modify a device removes manufacturer protecons.
● Devices covered by this protecon plan must be in an approved case. Damage that occurs in transit to
or from the school site or school acvies when the device is not housed in an approved case is not
covered under this policy.
● Enrollment in this program does not cover: Dishonest, Fraudulent, Intenonal, Negligent/Criminal Acts.
● The enrollment cost is non-refundable. If a student leaves the district before December 1st this amount
will be prorated.
Employee/Student Name: ____________________________ __________________________________
Printed Signature Date
Parent or Guardian Name: ____________________________ __________________________________
( For students only ) Printed Signature Date
Office Use Only: Payment Informaon:
● $________ Payment Amt. Enclosed. FORM OF PAYMENT: ( circle ) Cash Check #______
NOTES:
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