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Student Electronic Learning Device Request

Please complete the form below. Required fields marked with an asterisk *

Parent/Guardian Information

Contact Information
Parent/Guardian Relationship to Student*
Answer required for "Parent/Guardian Relationship to Student"
Does the student have access to a computer?*
Answer required for "Does the student have access to a computer?"
Does the student have internet access?*
Answer required for "Does the student have internet access?"

Student Information

 
Grade level*
Answer required for "Grade level"
I understand that I am permitted only 1 device per student. I understand that the school has a record of all devices which were distributed, even those devices which were mailed home to families in the Spring of 2020. *
Answer required for "I understand that I am permitted only 1 device per student. I understand that the school has a record of all devices which were distributed, even those devices which were mailed home to families in the Spring of 2020. "
I prefer the following device:*
Answer required for "I prefer the following device:"
I understand that both student and parent/guardian will need to sign a "Student Device Loan Agreement" form. The loan agreement form will be emailed to both student and parent/guardian. To pick up the electronic device, the signed form will need to be submitted to Ms. Keren in room 208A.*
Answer required for "I understand that both student and parent/guardian will need to sign a \"Student Device Loan Agreement\" form. The loan agreement form will be emailed to both student and parent/guardian. To pick up the electronic device, the signed form will need to be submitted to Ms. Keren in room 208A."
Confirmation Email