2025-26 Chromebook Agreement Form

1
As we prepare for the year ahead, we want to ensure that every student in grades 1-5 will receive a Chromebook for the school year. Please complete the form below to indicate that you have read and agree to our Chromebook policy.
2
Student #1 Name* This field is required.
First Name
Last Name
3
2025-26 Grade for Student #1* This field is required.
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
4
Would you like to add another student?
YESNO
5
Student #2 Name
First Name
Last Name
6
2025-26 Grade for Student #2
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
7
I, Parent First Name Parent Last Name understand that JCDSRI will lend a Chromebook(s) to my child(ren) and that our family is responsible for the safekeeping of that technology and its charger(s) . If the Chromebook(s) or charger(s) become damaged, broken or lost, I am responsible to reimburse JCDSRI $250 per Chromebook and $50 per charger. This will help cover the cost of replacing the technology.
8
Parent/guardian email
example@example.com
9
Parent Signature
Clear
10
Today's Date
Should be Empty: