Complete the form to apply to the waitlist today! General Information: First Name Please enter your first name. Last Name Please enter your last name. Email Address (Optional) Please enter your email address. Phone Number Please enter your phone number. Home Address: Address Please enter your home address. Apt / Ste # City Please enter your city. ST Please enter your state. Zip Code Please enter your zip code. Date of Birth: MM / DD / YYYY Gender: Male Female Non-Binary Choose Not To State Ethnicity: Asian / Asian American Black / African American Hispanic / Latinx Indigenous / Native American Native Hawaiian / Pacific Islander White / Caucasian Choose Not to State Disability / Diagnosis: Breast Cancer Cognitive Developmental Disability General Cancer Hearing Learning Disabled Mental / Emotional Multiple Disability Physical Substance Abuse Systems Disease TBI Vision Other Name Other Disability or Diagnosis Benefits / Services Received: Calfresh MediCal SSI VA Benefit Recipients Section 8 / HUD Public Housing Recipient Caregiver / Service Provider: I am a Caregiver. I am a Service Provider. I neither a Caregiver nor Service Provider. Annual Income Information: Employment / Job General Assistance (GA) Pension / Retirement Self-Employed / Business SSDI SSI Other Name Other Income Marin County Residency: Yes, I currently live in Marin County. No, I do not live in Marin County. Home Type: Single-Family Home Townhouse / Condo Apartment Mobile Home Facility Transitional Choose Not To State Occupancy: Own Rent Choose Not To State Digital Access: Do you have access to a device (made within the last 2 years) that can go online? Yes No Do you currently have access to high-speed internet? Yes No What will be the primary use for this Chromebook? Next Step: Confirm Your Application Go Back to the Digital Access for All Information Page
