Internet Request - ARC

Internet Request

Fill in your information below to qualify for low-cost internet.
Currently, there is a free Chromebook offer that is only available in select CA zip codes.

Do you currently have internet?/¿Actualmente tienes internet?*

Primary Language/Idioma*

Name/Nombre*

First Name

Last Name

Do you have a cell phone?/Tiene un telefono celular?*

Phone*

Email

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Government Assistants/Asistencia de Gobierno? Check all that apply *

SNAP/EBT Food Stamps (CalFresh) Medi-Cal (Medicaid) SSI (Supplemental Security Income) SSDI (Social Security Disability) NSLP (National School Lunch Program) Public Housing Assistance or Section 8 voucher Lifeline Other I am not sure

-SNAP, EBT food stamps, and CalFresh provide assistance in purchasing food for the home. -Medi-Cal is health insurance provided by California. -Supplemental Security Income is government program that provides stipends to low-income people who are aged 65 or older. -Social Security program that pays monthly benefits to you if you become disabled before you reach retirement age. -National School Lunch Program is free or reduced meals at school. -Public Housing Assistance and Section 8 vouchers provide assistance with affordable housing. -Lifeline Program that provides free or low cost phone service

How did you hear about us?*

Other organizations include but are not limited to: YMCA, Boys and Girls Club, your School District, your local government, etc.

Other*

Name of School District*

Name of Friend/Family *

Please enter first and last name

Please confirm if you would prefer to be contacted back via Text. A representative will respond back within two business days. Only select Phone Call if you are unable to communicate with us through text. (call back times can take longer than a week due to program popularity). Por favor, confirme si prefiere que nos contactemos con usted por medio de mensaje de texto. Un representante responderá dentro de dos días hábiles. Solo seleccione Llamada telefónica si no puede comunicarse con nosotros por mensaje de texto. (Los tiempos de devolución de llamadas podrán tardar más de una semana debido a la popularidad del programa)*

Check if you would NOT like to receive future news, events and information from human-I-T

Opt-out

Campaign Source

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Campaign Medium

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Campaign Term

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Campaign Content

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Campaign Name

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GCLID (Google Click Identifier)

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