2025 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
  • This program is not for staff with occasional/casual client interactions
  • Make sure they have internet at home BEFORE applying for a laptop
  • Laptops are typically shipped within 2 weeks
  • 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.
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! Because this program is federally funded the laptops are considered federal property --so there are a lot of rules to follow between submitting this application and when the laptop surveys are complete. :)

Privacy Notice Statement: All information submitted in this application will be protected via Personally Identifiable Information (PII) best practices. 
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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
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)
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.
 *
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