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Chromebook Request Form
Please complete this form to secure a Chromebook for your child. You must complete a separate form for each student. Please complete the form in its entirety.
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* Indicates required question
Email
*
Your email
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Student's Grade
*
Choose
K
1
2
3
4
5
6
7
8
9
10
11
12
Student's School
*
Durham Nockamixon Elementary School
Springfield Elementary School
Tinicum Elementary School
Palisades Middle School
Palisades High School
Other:
A copy of your responses will be emailed to the address you provided.
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