JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Student Device Physical Damage Form
Sign in to Google
to save your progress.
Learn more
What school do you or your child attend?
Horace Greeley High School
Seven Bridges Middle School
Robert E. Bell Middle School
Douglas Grafflin Elementary School
Roaring Brook Elementary School
Westorchard Elementary School
Other:
Clear selection
Student Name
Your answer
Contact e-mail address
Your answer
Contact phone number
Your answer
Device Type
iPad
Surface Go
Other:
Clear selection
Device number (printed on a sticked on the back of the device)
Your answer
Details (please be as detailed as possible)
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Chappaqua Central School District.
Does this form look suspicious?
Report
Forms
Help and feedback
Help Forms improve
Report
