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Please be advised that this form should be used to capture information for students in one household.

If you would like to supply information for children in multiple households, please complete a separate form.

Are you filling out this form for your household?

Please ensure that you have the information such as your ID card or the ID card of the guardians in the household to complete the survey.

Applicant Information

This section is for persons who may be filling out this survey on behalf of someone else who does not live in your household.

Gender

Date of birth

Date Picker

Information on Household

The household is the physical location where the students live together. Ensure that this section is used to submit information for only one (1) household.

Is there electricity in the household?

Is there internet access in the household?

Is there a television in the household?

Are there devices that can be used for e-learning in the household?

Select the type of devices available in the home

Primary Guardian Information

Use this section to submit information on the primary guardians.

Guardian 1 - Full Name

Guardian 1 - Gender

Guardian 1 - Is this person employed?


Guardian 2 - Full Name

Guardian 2 - Gender

Guardian 2 - Is this person employed?

Student Information

It is important that we understand the needs of all students in the household. Please provide accurate and complete information for this part of the survey.

Student 1 - Details

Student 1 - Gender

Student 1 - Has this student ever logged into online classes?

Student 1 - Was a device requested for this student before?

Student 1 - Was this student issued a device from the Ministry of Education/School?

Student 1 - Is the device still working?

Student 1 - Was the device returned?

Student 1 - Does this student need a device?

Student 1 - Would you like to submit information for another student?


Student 2 - Details

Student 2 - Gender

Student 2 - Date of Birth

Date Picker

Student 2 - Has this student ever logged into online classes?

Student 2 - Was a device requested for this student before?

Student 2 - Was this student issued a device from the Ministry of Education/School?

Student 2 - Is the device still working?

Student 2 - Was this device returned?

Student 2 - Does this student need a device?

Student 2 - Would you like to submit information for another student?


Student 3 - Details

Student 3 - Gender

Student 3 - Date of Birth

Date Picker

Student 3 - Has this student ever logged into online classes?

Student 3 - Was a device requested for this student before?

Student 3 - Was this student issued a device from the Ministry of Education/School?

Student 3 - Is the device still working?

Student 3 - Was the device returned?

Student 3 - Does this student need a device?

Student 3 - Would you like to submit information for another student?


Student 4 - Details

Student 4 - Gender

Student 4 - Date of Birth

Date Picker

Student 4 - Has this student ever logged into online classes?

Student 4 - Was a device requested for this student before?

Student 4 - Was this child issued a device from the Ministry of Education/School?

Student 4 - Is the device still working?

Student 4 - Was the device returned?

Student 4 - Does this student need a device?

Student 4 - Would you like to submit information for another student?


Student 5 - Details

Student 5 - Gender

Student 5 - Date of Birth

Date Picker

Student 5 - Has this student ever logged into online classes?

Student 5 - Was a device requested for this student before?

Student 5 - Was this child issued a device from the Ministry of Education/School?

Student 5 - Is the device still working?

Student 5 - Was the device returned?

Student 5 - Does this student need a device?

Use the following area to provide any further information that would be relevant

I certify that the information provided is true to the best of my knowledge.