Title 1 Tech Application For Student/Family

您的瀏覽器尚未啟用 JavaScript，因此無法開啟檔案。請於啟用後重新載入頁面。

Please complete this application so we have a better understanding of the technology need.

Please complete the application for the student that needs the device.

Request for a device for the family should be completed by the primary contact for this request.

Student's First and Last Name *

Parent's/Guardian's First and Last Name *

Home Address *

Parent/Guardian Email Address *

Parent/Guardian Phone Number *

Student's School Name and Address *

Student's Grade Level *

Student's Age *

Does student attend a Title 1 School
*

Yes

其他：

必填

Does the student get free or reduced lunch?
*

Yes

How will getting a laptop help you?
*

Explanation of Need
*

If Selected, Will You be Willing to Provide Us a Testimonial Regarding Your Experience Receiving Support From Our Program
*

If Selected, will you be Willing to Complete a Quarterly Questionnaire survey Regarding the Impact it Has Had on the Students and/or the Family?
*

提交

清除表單

請勿利用 Google 表單送出密碼。

Google 並未認可或建立這項內容。檢舉濫用情形 - 服務條款 - 隱私權政策