Remote Learning Device Request

Remote Learning Device Request

Devices will be loaned on a first come, first served basis.
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
Name

First Name Last Name
Grade Level
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
Should be Empty: