Chromebook Request Form

Positive Education Program (PEP) is providing Chromebooks to all non-graduating students for use during this school closure. Each child will be assigned their own Chromebook (known as a 1:1 program) for use in class and at home (during emergency closures/disruptions), for as long as they are enrolled at PEP. This device allows access to educational content on websites chosen by PEP.

If you have trouble completing this form, or have questions, please contact Lisa Martin at 216-361-7760 x179 or via email at lmartin@pepcleve.org.

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* 1. Student's FIRST Name

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* 2. Student's LAST Name

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* 3. Parent/Guardian's FIRST name

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* 4. Parent/Guardian's LAST Name

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* 5. Parent/Guardian's Email

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* 6. Parent/Guardian's Phone Number (10 digits no spaces or dashes)

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* 7. Parent/Guardian's Phone Number Type

Cell Phone

Land Line

Other (please specify)

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* 8. Will you accept text messages on the phone number above?

Yes

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* 9. IMPORTANT DELIVERY INFORMATION
Chromebooks will be mailed via UPS. UPS will be delivering the Chromebook to the student’s home address on file at PEP. UPS will require the signature of an adult age 21 or older for delivery. A photo ID will be required. They will make three attempts to deliver the package. A note will be placed on your door if you are not home and you will have the opportunity to redirect the package to a local UPS access point (CVS, etc.) for pick up. If not picked up within seven calendar days, the package will be sent back to us.

If this method does not work for your household, please write us a short note below about your concern and we will contact you directly to resolve. We cannot provide exact times and dates when Chromebooks will be delivered and families do not have a choice of delivery times.

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* 10. Street Address Where the Student Lives (must match address on file at PEP)

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* 11. City

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* 12. ZIP Code

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* 13. Is this a foster home or group home?

Yes

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* 14. What is the best phone number to use for troubleshooting delivery issues? This should be someone's phone number at the student's address. (10 digits no spaces or dashes.)

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* 15. Which of the following best describes your household’s Internet access?

We access the Internet only through smartphones.

We have a High-Speed Internet Services Provider like DirectTV, WOW!, AT&T U-verse or Spectrum.

We don’t have our own Internet access. We use public Wi-Fi, other people’s access or don’t use Internet at all.

I'm not sure/I don't know.

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* 16. Which of the following best describes your household’s WiFi/Mobile Hot Spot use?

Our smartphone is the only way we access the Internet. We HAVE used our smartphone as a Mobile Hot Spot before.

Our smartphone is the only way we access the Internet. We HAVE NOT used our smartphone as a Mobile Hot Spot before.

We use Wi-Fi through our High-Speed Internet Services Provider.

We don’t have our own Internet access.

I'm not sure/I don't know.

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* 17. Which of the following best describes the computers/devices in your household?

Our household has only flip-phones or land-lines – there are no smartphones, laptops, tablets, desktops or other computers for personal use that could connect to the Internet.

Our household has Smartphones and/or tablets but there are no laptops, desktops or other computers for personal use.

Our household has a laptop, desktop or Chromebook for personal use.

Our household has no Internet or phone.

I'm not sure/I don't know.

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* 18. Which of the following best describes the PEP student’s access to a computer or devices?

The PEP student does not have a device of their own.

The PEP student only has a flip phone (or phone that is not capable of accessing the Internet).

The student has his/her own Smartphone or tablet, but no laptop, desktop or Chromebook.

The student has his/her own laptop, desktop or Chromebook.

I'm not sure/I don't know.

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* 19. Please list any concerns you have about your Internet access or the PEP student’s use of a PEP Chromebook.

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* 20. CHROMEBOOK POLICY and ACCEPTANCE
A parent/guardian (student if 18 or older) must read and accept PEP’s Chromebook Policy before we will mail a Chromebook to a student. The Chromebook Policy can be found on our website here: www.pepcleve.org/chromebooks. Once you have read the policy, please indicate your acceptance by selecting the box below.

By selecting this checkbox, I affirm that I am the parent/guardian of the student listed above (or the student if age 18 or older), and have read PEP’s Chromebook Policy. I agree to abide by all terms. In consideration of the privileges and opportunities afforded by the use of Chromebooks, I hereby release PEP and its agents from any and all claims of any nature arising from my student’s use or inability to use PEP’s technology and computer resources.

(To be read to the parent/guardian.) I have provided my verbal consent for a PEP staff member to complete this form on my behalf. I affirm that I am the parent/guardian of the student listed above (or the student if age 18 or older), and I have read PEP's Chromebook Policy online or have agreed to review the policy prior to the student using the Chromebook. I have discussed the main points of the policy with a PEP staff member. I agree to abide by all terms. In consideration of the privileges and opportunities afforded by the use of Chromebooks, I hereby release PEP and its agents from any and all claims of any nature arising from my student's use or inability to use PEP's technology and computer resources.