First Name (Required)

Last Name Name (Required)

Your Email (Required)

District Name and Address (Required)

School Name and Address (Required)

Your Position at the School (Required)

Your Phone Number (Required)

School Principal's Name (Required)

Name and Contact Info for Contact if Different than Applicant or Principal

Are you a Title I School or District (Required)

Number of Students in the District/School on Free and Reduced Lunch (Required)

Number of Students in Need of Internet Connectivity at Home (required)

Number of Students without Laptop/Computer at Home (required)

Number of Laptops/Computers Needed for the School or Classroom (required)

Explanation of Need (required)

If Selected, Will You be Willing to Provide Us a Testimonial Regarding Your Experience Receiving Support From Our Program (required)

If Selected, for Receiving Devices for Students to Take Home, Will you be Willing to Complete a Questionnaire in the Future Regarding the Impact it Has Had on the Students and Their Families? (required)