SmMS Chromebook & Hotspot Request Form

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In order to request a school Chromebook or hotspot, this form should be completed by a parent or guardian. If you have more than one child attending Smithfield Middle School, please complete this form for each child that needs a device. In order to receive a device, this form must be completed. The school will not distribute a device without completing this form. You will receive an email regarding when you are able to come to Smithfield Middle to pick up the device.

Email *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Phone Number *

Student's First Name *

Student's Last Name *

Student's Grade Level *

Student's PowerSchool Number or Student ID

Does your student need a Chromebook? (Note: Details regarding device pick up will be emailed to you after you submit the form.) *

Yes

Does your student need a hotspot for internet access? (Note: Details regarding hotspot pick up will be emailed to you. Hotspots are based on district availability.) *

Yes

JCPS Home Use Technology Loaner Agreement

By submitting this form, you are stating that you have read and agree to the terms of usage provided in the JCPS Home Use Technology Loaner Agreement. *

I agree that I have read and agree to follow the JCPS Students/Parents Technology and Digital Citizenship Agreement.

I do not agree with the terms. I understand that I will not be able to receive a device from Smithfield Middle.

Send me a copy of my responses.

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