Remote Learning Device Request
Priority will be given to students most in need.
Parent/Guardian Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Yes
No
Do you have access to a computer?
Do you have a smartphone?
Do you have Internet access?
Student Information
School Name
Name
First Name
Last Name
Student ID
Grade Level
Family Child Care
3K
Pre-K
Kindergarten
Grade 01
Grade 02
Grade 03
Grade 04
Grade 05
Grade 06
Grade 07
Grade 08
Grade 09
Grade 10
Grade 11
Grade 12
Please make sure the address you enter below is accurate. This device will be sent to the address.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
Clear
Submit
Should be Empty: