SY21-22 PCA - Student Information Form
Please complete this form to provide the most up-to-date information
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Email *
STUDENT FIRST NAME *
STUDENT LAST NAME *
STUDENT ID # *
DO YOU HAVE INTERNET ACCESS AT HOME? *
HOW DO YOU ACCESS THE INTERNET AT HOME? *
Required
WHAT IS YOUR GRADE LEVEL *
WHAT IS YOUR T-SHIRT SIZE *
STUDENT CELL PHONE NUMBER *
STUDENT HOME ADDRESS *
I UNDERSTAND THAT IF I HAVE A CPS DEVICE ASSIGNED TO ME AND I DIDN'T RETURN IT BACK TO PROSSER, I DO NOT QUALIFY TO RECEIVE AN ADDITIONAL DEVICE. *
I UNDERSTAND THAT IF WE GO INTO REMOTE AND A DEVICE NEED TO BE PICKED UP THAT IT CAN TAKE UP TO 60 - 90 MINUTES TO RECEIVE THE DEVICE *
I UNDERSTAND THAT I HAVE TO LOG INTO THE COMPUTER BEFORE LEAVING PROSSER WITH MY CPS USERNAME AND PASSWORD *
I UNDERSTAND THAT STUDENTS UNDER 18 MUST HAVE THEIR PARENT OR LEGAL GUARDIAN PRESENT TO PICK UP THE COMPUTER *
I UNDERSTAND THAT A PARENT MUST BRING AN ID OR A UTILITY BILL IN ORDER TO PICK UP THE COMPUTER.  NOTE:  STUDENTS 18 OR OLDER MUST BRING THEIR STUDENT ID OR MAIL FROM THEIR RESIDENCE. *
PARENT / GUARDIAN NAME #1 *
RELATIONSHIP (PARENT / GUARDIAN NAME #1) *
TELEPHONE NUMBER (PARENT / GUARDIAN NAME #1) *
EMAIL ADDRESS (PARENT / GUARDIAN NAME #1) *
PARENT / GUARDIAN NAME #2
RELATIONSHIP (PARENT / GUARDIAN NAME #2)
TELEPHONE NUMBER (PARENT / GUARDIAN NAME #2)
EMAIL ADDRESS (PARENT / GUARDIAN NAME #2)
A copy of your responses will be emailed to the address you provided.
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