Name (First and Last):
*
E-mail:
Telephone Number:
*
Address (Street,City,State,Zip):
*
I'd prefer a:
No preference
PC
Mac
School, program or "not applicable":
Current grade or class:
Pre-K, K
Grades 1-6
Grades 7-12
College
Graduate
Other
Computer to be used for (max 120 chars):
List computer users (Names of children, partner, siblings) AND Ages:
*
How did you hear about Tech for All?
*
Agency
Friend
School
Church
Social Worker
Web site
Name of Agency, Friend, School, Church or Social Worker:
*
I acknowledge NO LAPTOPS are available:
*
I understand I am requesting a DESKTOP computer.
OR, I understand I will NOT receive a computer.
Enter the code as it is shown: *
*
Submit
Fields with an asterisk (*) are REQUIRED. By clicking on Submit, I understand that volunteers contribute, refurbish and distribute the computers on a "First Come / First Serve" AS AVAILABLE basis. I understand this TAKES TIME and I AM WILLING TO WAIT. I understand the information I supply is retained on an unencrypted, unsecured website.
Should be Empty: