Agreement Request for Itinerant Services

Agreement Request for Itinerant Services

Arizona State Schools for the Deaf and the Blind
Partnering with ASDB for Itinerant Services

This form is the first step in establishing an agreement between ASDB and your district/charter to provide Itinerant Services. Please provide the requested information to help us create a draft agreement.
Submitter Name*

First NameLast Name
Submitter Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Authorized Signers
Please provide the information of two staff members that are authorized to sign this agreement on behalf of your district or charter. (Commonly: Special Education Director, Superintendent, Business Manager)
First Authorized Signatory Name*

First NameLast Name
First Authorized Signatory Title*
First Authorized Signatory Email*
example@example.com
Second Authorized Signatory Name*

First NameLast Name
Second Authorized Signatory Title*
Second Authorized Signatory Email*
example@example.com

After submitting, please confirm receipt with the ASDB team by emailing jason.lilly@asdb.az.gov and debi.lozano@asdb.az.gov.

A blank agreement will be issued for your review once all information is received. Please note that service availability, including in-person options, varies by location; virtual services may be available depending on ASDB staffing capacity.
Should be Empty:

Authorized Signers