Technology Access for Distance Learning

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This form is to help GWCA determine which of our families have internet and computer access in the home

Email *

George Washington Carver Family Information

Identifying Technology Needs/Resources

Parent Name *

Parent Phone Number *

Parent Email Address *

Parent Home Address *

Scholar Full Name & Grade *

Scholar Full Name & Grade

How many school age children do you have in the home? *

Technology Access

Identifying Technology Support Needs

Do your scholars have access to technology from 9a-2p? *

Yes

What type of internet access do you have at home? *

Broadband

Dial-up

Only have access to the internet on my cell phone

Do not have access to the internet

Do you have a limited amount of data allowed for your internet access? *

Yes

No access

Academic Support

Identifying Academic Support Needs for GWCA Students

Are all the adults in the household currently working? *

Yes, all adults in the household are currently working

Some adults in the household are working, but some are not

No adults in the household are currently working

Is there an adult home to help with academic work from 9a-2p Monday-Friday?

Yes

Clear selection

Are you currently working from home? *

Yes

Are any of the adults in your household a medical professional or first responder? *

Yes

If provided technology equipment from George Washington Carver for your child(ren)’s use with school work, would you be willing to sign an agreement that include terms of safe return of the equipment back to the school upon the close of the school year? *

Yes

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