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Student Electronic Learning Device Request
Student Electronic Learning Device Request
Please complete the form below. Required fields marked with an asterisk *
Parent/Guardian Information
Contact Information
Parent/Guardian First Name
*
Answer Required
Parent/Guardian Last Name
*
Answer Required
Parent/Guardian Email
*
Answer Required
Parent/Guardian Phone
*
Number Required
Parent/Guardian Relationship to Student
*
Answer Required
Please Select
Mother
Father
Other Guardian
Grandmother
Grandfather
Aunt
Uncle
Cousin
Student (Self)
Other Family
Does the student have access to a computer?
*
Answer Required
Please Select
Yes
No
Does the student have internet access?
*
Answer Required
Please Select
Yes
No
Student Information
Student First Name
*
Answer Required
Student Last Name
*
Answer Required
Student School Email Address (@nycstudents.net email)
*
Answer Required
Student ID/OSIS Number
*
Answer Required
Grade level
*
Answer Required
9
10
11
12
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
Yes
No
I prefer the following device:
*
Answer Required
iPad
Chromebook
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
Yes
No
Confirmation Email
Confirmation Email
*
Email Required
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