Donation Application
Si necesita una forma Española, entra aquí: http://www.rebootforyouth.org/espantildeol

Submit a request for a computer from Reboot for Youth

First Name: *
Your answer
Last Name: *
Your answer
Email: *
Your answer
Phone Number: *
Your answer
Please select your position:
Number of Students in Family:
Your answer
Code:
For counselors only
Your answer
Please provide a short description of financial situation:
to determine if recipient(s) genuinely needs a computer
Your answer
Number of Computers Needed: *
Your answer
If you could give consent in having your photo taken for possible posting to the company website, please select yes below. *
The Reboot Team is currently interested in gathering photos of computer recipients at delivery meetings. This is intended to provide a photographic timeline of our activities, and may be posted for advertising purposes on the company website (http://www.rebootforyouth.org)
If selected "Yes" above, do you also give consent for your name to be added next to the picture online?
How would you like to be contacted?
Email, phone, etc.
Your answer
Any last remarks before submitting for approval?
Your answer
Submit
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