Remote Learning Device Request
DOE Ticket Number *
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Student's First Name
Student's Last Name
Student ID#
Grade Level
Date of Birth
MM
/
DD
/
YYYY
Home Address
Apt/Suite/Floor
Father / Mother First Name
Father / Mother Last Name
Email address
Telephone Number
Home Address
Apt/Suite/Floor
Does the student live in a shelter?
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Does the student have access to any of the devices listed below?
Does the student have Internet / WIFI access?
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