Device Request

Parent Name(Required)

First Last

Please list the name of the parent/guardian that completed the enrollment application.

Email(Required)

Phone(Required)

Shipping Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please list an address where someone will be available when item(s) are delivered if possible.

Do you need an internet device (mifi)?(Required)

Yes

Number of Chromebooks Requested

Name of Student(s)(Required)

List the name(s) of the student(s) that are requesting a Chromebook

Phone

This field is for validation purposes and should be left unchanged.

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