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Remote Learning Device Request
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* Indicates required question
Student's First Name
Your answer
Student's Last Name
Your answer
Student ID#
*
Your answer
Class
Your answer
Date of Birth
MM
/
DD
/
YYYY
Home Address
Your answer
Apt/Suite/Floor
Your answer
Father / Mother First Name
Your answer
Father / Mother Last Name
Your answer
Email address
Your answer
Telephone Number
Your answer
Does the student live in a shelter?
YES
NO
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Does the student have access to any of the devices listed below?
Desktop Computer
Tablet / Ipad
Laptop
Smart Phone
None of the above
Other:
Does the student have Internet / WIFI access?
YES
NO
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