Halifax County Schools Chrome Book Distribution -- Parent Hardship Form  2021_2022
Completion of this form does not guarantee a waiver of payment.
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1.  Parent(s) Name *
2.  Parent Contact Number (please include area code) *
3.  What is your email address?  (Skip this question if you do not have an email address)
4.  List the name of your 1st child. *
5.  Which school does your 1st child attend? *
6.  What is the grade level of your 1st child? *
7.  List the name of your 2nd child. (if not applicable, skip to question 16)
8.  Which school does your 2nd child attend?
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9.  What is the grade level of your 2nd child?
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10.  List the name of your 3rd child. (if not applicable, skip to question 16)
11.  Which school does your 3rd child attend?
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12.  What is the grade level of your 3rd child?
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13.  List the name of your 4th child. (if not applicable, skip to question 16)
14.  Which school does your 4th child attend?
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15.  What is the grade level of your 4th child?
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16.  Please provide an explanation of your hardship situation so that we can assist you as much as we can.
17.  If you are not able to pay the $40 per device, how much can you afford to support with providing your child(ren) devices to enable learning? *
18.  If a payment plan was offered, are you able to pay $4 per month per device for 10 months, (i.e. 1 device = $4 per month for 10 months, 2 devices = $8 per month for 10 months)? *
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