Saiph Stars Application Form

Application

Please provide us with the following information so that we can prepare the iPad for your child.
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Contact information

Please provide 2 contact numbers
Contact #1*
Contact #2*
Email Address *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
YesNo
Do you want us to include?
YesNo
YesNo
YesNo
Please provide your Zoom information. Without this information, Zoom access cannot be configured due to device restrictions.*
YesNo
YesNo
Tehillim Name *
Please briefly describe your child's situation and how he/she would benefit from the Saiph Stars program? *
iPad Lending Agreement Acknowledgment

Please Note: By accepting an iPad through our lending program, you agree to take reasonable care of the device. In the event that the iPad is lost, stolen, or damaged due to causes other than normal wear and tear (e.g., cracked screen, water damage, misuse, etc.), your family agrees to be responsible for the cost of repair or, if the device must be replaced, a replacement fee of up to $500.
Parent/Guardian Initials*
I have read and agree to the iPad Lending Agreement above.
How did you hear about us*
Wishing your child a Refuah Sheleimah!
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Application