Enter First Name

Enter Last Name

Enter your e-mail address here

Enter your Phone Number [(xxx) xxx-xxxx] 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: Child 5 Full Name: Relationship: Age: Grade: School Attending: Child 6 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?

Yes No

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

(Please select all that apply)

Library After School Program Church Other

04. Do you have internet capbailities in your home, such as telephone service or high-speed connectivity?

Yes No

05. 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 below to print an Adobe Acrobat application form.