2026 Digital Equity Project Laptop Application
THIS FORM IS FOR CASEWORKERS, SOCIAL WORKERS, AND DIRECT SERVICE PROVIDERS ONLY.
(This form is not for clients to fill out.)

RULES OF THIS PROGRAM:

  • You must be meeting regularly (at least monthly) with client on a 1:1 long-term (3 month minimum) basis
  • Your client is working on employment, housing, parenting, education, or healthcare goals
  • Your client must demonstrate the basic ability to use technology and care for a device
  • This program is not for staff with occasional/casual client interactions
  • Laptop recipient must be in stable housing --we do not distribute laptops to people living in shelters/vehicles since it's difficult to protect the laptop from theft or damage
  • Make sure they have internet at home BEFORE applying for a laptop
  • Laptops are typically shipped within 3 weeks
  • Laptops must be sent to a secure address - if you have concerns about the security of your client's residence, have the laptop sent to your office.
  • In order to keep the laptop, clients must complete this online survey 3-6 months after receiving the laptop, and by completing this application you agree to helping ensure this happens.
This program is federally funded until the end of 2026.  These laptops are considered federal property, so please be sure to read the rules carefully before submitting an application. If your client has already received a laptop from us, their application will be declined. If their laptop was lost or damaged, they need to contact laptophelp@danenet.org for repair/replacement.

If you have questions contact Allie via allie@danenet.org or Shawn via shawn@danenet.org. Thank you for reading all this and sorry for the long form!

Privacy Notice Statement: All information submitted in this application will be protected via Personally Identifiable Information (PII) best practices. 
Sign in to Google to save your progress. Learn more
Email *
Direct Service Provider Organization *
Where should this laptop be delivered, to the laptop Recipient or referring Provider at their organization? Please select the most secure location for delivery as FedEx may deliver laptops at any time of day/week.  *
Laptop Recipient First Name *
Laptop Recipient Last Name *
Recipient Phone Number
Recipient Email (We strongly recommend providing an email or creating an email with your client in order to send them the feedback survey directly. Please do not enter your email in this line - write N/A if the client does not have an email. Either an email or a phone number is required to approve applications.) *
Recipient Street Address *
Recipient City/State/Zip *
CAM tag # of laptop (Required if from a Bulk Order)
Which of the following services would your client benefit from in addition to a free refurbished laptop and tech support for that laptop? (Check all that apply) *
Required
Does anyone in the computer recipient's household identify with any of the following eligibility statements? (Internet speed test available online at https://www.speedtest.net/) *
Required
Does anyone in Recipient's household identify with any of the following statements? Please check all that apply *
Required
How many individuals live in Recipient household? *
Which of the following best describes Recipient? *
Gender of Recipient *
Recipient Age *
Caseworker name (first and last) *
Caseworker email *
Caseworker phone *
Caseworker Org Address (if we are shipping to Direct Service Provider Organization) *
Are you confident that your client can keep the laptop safe from damage or theft? *
What are this client's specific goals in regards to having a laptop? (Check all that apply) *
Required
How often are you meeting with this client? *
Do you anticipate you'll still be regularly meeting with this client in 3-4 months? *
By submitting this application I confirm the above information to be true and I'm able to provide further documentation upon request.  

I have also explained to my client that in order to keep the laptop, they will be required to complete an email/online survey in three months regarding progress towards their online objectives.

I agree that I will not submit a duplicate application for this person if the laptop is lost/damaged and instead reach out to DANEnet right away.
 *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of DANEnet.

Does this form look suspicious? Report

Google Forms