SY21-22 PCA - Student Information Form

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Please complete this form to provide the most up-to-date information

STUDENT FIRST NAME *

STUDENT LAST NAME *

STUDENT ID # *

DO YOU HAVE INTERNET ACCESS AT HOME? *

Yes

HOW DO YOU ACCESS THE INTERNET AT HOME? *

HOME COMPUTER

CPS TABLET

PERSONAL CELL PHONE

OTHER DEVICE

I DON'T HAVE THE INTERNET

Required

WHAT IS YOUR GRADE LEVEL *

9TH

10TH

11TH

12TH

WHAT IS YOUR T-SHIRT SIZE *

2XL

3XL

4XL

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. *

YES

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 *

YES

I UNDERSTAND THAT I HAVE TO LOG INTO THE COMPUTER BEFORE LEAVING PROSSER WITH MY CPS USERNAME AND PASSWORD *

YES

I UNDERSTAND THAT STUDENTS UNDER 18 MUST HAVE THEIR PARENT OR LEGAL GUARDIAN PRESENT TO PICK UP THE COMPUTER *

YES

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. *

YES

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)

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