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HTCTU BrailleNote Loan Program

Nomination Form for California Community Colleges

Individuals interested in nominating a student to borrow a BrailleNote for one academic year should complete this form. If you are nominating more than one student, please complete an application form for each student enrolled at a California Community College.  You may also read additional information about the BrailleNote device.  If you have any questions, please Thank you for your interest! 

Person nominating student:

Student Nominee:

(please enter the student's address information below)

Student's Skills:

Student's Classes:

BrailleNote Use:


Equipment Return:


Do you agree to write a brief report by June 30, 2014, which details the successes and difficulties encountered during the semester? This report will be sent via e-mail to Gaeir Dietrich at the High Tech Center Training Unit.


Please indicate if you are just renewing the BrailleNote:


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