Philadelphia Children's Connection - computer application> computers in hand -

Self (If self, skip to Part B)

Parent/Relative

Teacher

Other

Applicant’s Name

Applicant’s Email

Applicant’s Home Address

Zip Code

Applicant's Home/Cell Phone (best way to reach you)

Student’s Name

Student’s Age

Student’s Grade

Student’s School

Student’s Email

Student’s Home Address

Number of Children in Household & Ages

$20,000 or below

$20,001-$25,000

$25,001-$30,000

$30,001-$35,000

$35,001 or above

Please state your need for a computer. Include your goals for the future, and how a computer might further your studies and/or other pursuits.

Do you have a computer in your home? If so, how would a second computer assist you?

Would anyone else in your household (siblings, parents, etc.) benefit from having a computer at home, and how?

On a scale of 1 to 5 (1= no knowledge, 5=advanced), how would you rate your knowledge of computers? Please explain.

Do you have access to a printer? Would you like to be considered for a printer donation? Please explain your printing needs.

Do you have a home telephone line (for dial-up service)? Are you able/willing to pay a low monthly fee for Internet service?

Please feel free to provide any additional information regarding your computer needs, family circumstances, etc.