Apply to UR SUCCESS Laptop Lending Program

Laptop Lending Application


I want to apply to participate in the Laptop Lending program.

APPLICANT INFORMATION
	First Name MI A value is required. A value is required. Last Name A value is required.
	E-mail A value is required.Invalid format.
	Home Address
	City	State	ZIP

	Mailing Address (If different than above)
	Address
	City	State	ZIP

	Phone Invalid format.	Cell Phone Invalid format.

	Gender:
	Birthdate: A value is required.Invalid format.Age: Grade: A value is required.Invalid format.


	How did you hear about UR SUCCESS?


	Have you read information on the UR SUCCESS web site about the Laptop Lending Program?		Yes No

	Do you understand and believe you can meet the requirements of this program?		Yes No

	Are you committed to completing this program?		Yes No

NARRATIVE QUESTIONS

	1. How will having a laptop computer help you?

	2. Why do you need a laptop computer?

	3. How will a laptop computer help you learn?

	4. What does success mean to you?

	5. What can you do to reach success?

	6. What do you consider your greatest accomplishment? Why was this achievement important to you?

	7. Joining the UR SUCCESS Laptop Lending program means making a commitment to take care of the laptop computer you would borrow and using it appropriately. Give an example of a time you were responsible for taking care of something important.

CONSENT & AGREEMENT
	Please make a selection.I have read the information about the UR SUCCESS Laptop Lending program, and if accepted, agree to comply with expectations during my entire program. I certify that I completed this application myself and that all of the statements made in this application are true to the best of my knowledge.

	By completing the "signature and date fields" below your are signing this application.

	Applicant: A value is required.Today's Date: A value is required.Invalid format.

	Parent/Legal Guardian: A value is required.A value is required.Today's Date: A value is required.Invalid format.A value is required.Invalid format.

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