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

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?

Yes
No

04. If No, where does your child access a computer?

(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?

Yes
No

04. If Yes, please check one.

Home telephone service
DSL/ADSL
Broadband (Cable)

 


06. Do you feel you may qualify for low-income?

Yes
No

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