Free Tablet Registration Form
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Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Last 4 of SSN
*
Date of Birth
*
-
Month
-
Day
Year
What Government Benefit Do You Have?
*
Please Select
Food Stamps
Medicaid (Attach Picture Of Card)
Free School Breakfast/Lunch - (Enter Child Info)
Federal Pell Grant
SSI
Section 8
Apply Based On Income - (Attach W-2)
WIC
Veterans Pension & Survivors Benefit
What School Do You or Your Child Attend?
*
Please Select
Miami Carol City Middle School
Miami Carol City High School
Miami Norland Middle School
Miami Norland High School
North Miami High School
Melrose Middle School
Brownsville Middle School
Scott Lake Elementary School
I-Tech Magnet School
Turner Tech
Miami Dade College
Broward College
Palm Beach State College
St. Thomas University
Florida International University
Florida Memorial University
Not Applicable
How did you hear about us?
*
Please Select
Flyer
Social Media
Friend/Family
Other
Who Receives Government Benefits? - **Note** If someone else receives the benefit, Please enter the information below
*
Myself
Someone Else
Please give reference of any two people whom you feel would qualfiy
Rows
Full Name
Contact Number
1
2
3
Comments
Questions, Comments
If Someone Else Receives Benefits, Please Click Here And Enter Their Details
Name 2
First Name 2
Last Name 2
Date of Birth 2
-
Month
-
Day
Year
Last 4 of SSN 2
School Name - If Applicable
If You Chose School Lunch Or Pell Grant In The Benefits Menu
Upload A Photo ID
Upload A Photo Of W-2 or First Page Of Tax Return (If Income Qualified)
Submit
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