Remote Learning Device Request

Please check here if you are a school staff member completing this survey on behalf of a parent/guardian. Please note that the contact information in the form must be the accurate, current contact information for the family, as this will be used to set up delivery of the device. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Parent/Guardian Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you have access to a computer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Do you have a smartphone? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Do you have Internet access? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Student Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Student ID# {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

The Student ID is printed on your child's report card.

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does the student live in a shelter? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Does the student’s family live with another family or other person because of loss of housing or as a result of economic hardship? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Is the student currently in foster care? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Does the student live in NYCHA housing? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }