Device Pick-up Appointment Form

Device Pick-up Appointment Form

Please fill this form if you are a parent/guardian of a student who needs a device for distance learning at home or a staff member who needs a device for remote work.
Please Choose

I am a parent/guardian - Student needs a deviceI am a staff member - I need a device
Staff Member Name

First NameLast Name
Staff Email
example@example.com
Department
Parent/Guardian Name

First NameLast Name
Student Name

First NameLast Name
Student ID Number
Parent/Guardian/Student Email
example@example.com
Phone Number

Area CodePhone Number
Name of person picking up the device

First NameLast Name
Appointment
3013 NW 11th St, Fort Lauderdale, FL 33311 954-792-6010
Should be Empty: