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Because you are requesting a loan of assistive technology services, we are asking you to provide information about yourself on this form. If you are requesting services on behalf of another, we will need additional information about that person. The MN STAR Program, who provided funds for items in the lending library, will use this information to administer and evaluate this program. Providing this information is voluntary and will allow you to receive these services. You can choose not to provide this information.
Any data that identifies you will be protected as private data. We can only share the information as described in this notice or with your permission.
By law, information can be shared with the Legislative Auditor and the Attorney General in the case of litigation. Information you provided would also be shared or released if a court orders it or a future state or federal law requires it.
The MN STAR Program is requiring your agreement in order to loan out assistive technology purchased with their funds. Your signature on this form indicates your agreement for the next year or until your membership expires. We will annually update this agreement. For each library item you borrow, there will be a survey provided by STAR which you must return.
By signing below, I indicate that I have read and understand the Tennessen Notice and that my information may be shared with the MN STAR program.
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