Survey
Computers for Kids
Parent/Legal Guardian Information
Enter First Name
Enter Last Name
Enter your e-mail address here
Child/Chidlren's Information
List each Child's Information
Child 1 Full Name: Relationship: Age: Grade: School Attending: Child 2 Full Name: Relationship: Age: Grade: School Attending: Child 3 Full Name: Relationship: Age: Grade: School Attending: Child 4 Full Name: Relationship: Age: Grade: School Attending:
01. Do you have children who are assigned homework requireing the use of a computer?
Yes No
02. Do you have a working compuer in your home at the present time?
04. If No, where does your child access a computer?
(Please select all that apply) Library After School Program Church Other
(Please select all that apply)
Library After School Program Church Other
03. Do you have internet capbailities in your home, such as telephone service or high-speed connectivity?
04. If Yes, please check one.
Home telephone service DSL/ADSL Broadband (Cable)
06. Do you feel you may qualify for low-income?
07. If Yes, you will need to fill in the computers for kids form?
(If you do or are not sure if you qualify, click the button below and fill in the form and we will make a determination. All information is kept strickly confidential. We will need to contact your references for verification.)
Chlick on this icon for submit application form