Application - kids@computers

1 26-0135 2012 - 12 Application kids@computers Scholarship Project Please print Please indicate what type of Social Benefits you are receiving Ontario Works ODSP Please attach verification if one of these 3 boxes are checked Subsidized Housing or NCBS Recipient or Welcome Policy Member Child's Information (Must be 8 14 years old) First name Last name Date of Birth (yyyy-mm-dd) Home address Apt. no. Buzzer code Postal code Home telephone # Parent(s) or guardian(s) living with the child First name Last name First name Last name If the child has any siblings between the ages of 8-14 living at this address, please list below: First name Last name Date of Birth (yyyy-mm-dd) Would your child need any support(s) in order to take part in a classroom setting? No Yes Your child should use the space on the back of this Application to tell us the reason(s) they need a computer in their home. Does your child currently have access to a computer in your home?

2 No Yes If "yes", please complete: Make /Model /Brand name Year Memory (RAM and MB or GB) Speed (MHz or GHz) Do you currently have internet in your home? No Yes Internet provider Have you or any family member ever received a computer from kids@computers or any other computer program? No Yes If "yes", when? Please attach a reference letter with this Application I understand that the Application becomes the property of kids@computers Scholarship Project. I declare that the above information is correct and I understand that the information provided may be verified. False information may result in disqualification. I agree to abide by the conditions of the scholarship. I understand that I may be asked to participate in an evaluation of this project. I understand that the decision of kids@computers Scholarship Project is final. Child's signature Parent/ guardian's signature Date (yyyy-mm-dd) Parent/ guardian's signature The personal information on this form is collected under the authority of the City of Toronto Act, 2006, s.

3 136 ( c) By-law #1123-2001 and may be shared with Ontario Works, as per Ontario Works Act 1997. The information is used to assess your eligibility for a kids@computers Scholarship. Questions about this collection can be directed to the Program Manager at kids@computers , 700 Lawrence Avenue West, Suite 330, Toronto, Ontario, M6A 3B3, or by telephone at 416-392-8610. or 26-0135 2012 - 12 Please ask your child to write a letter or draw a picture about why he / she would like a computer. He / she can use the space below, or can attach a letter or picture to this Application form. 26-0136 2012-12 Scholarship Application checklist 700 Lawrence Avenue West, Suite 330 Toronto, Ontario M6A 3B3 Application checklist The child applying must live in Toronto and be 8 to 14 years of age. Please complete all areas of the Application . The parent(s) / guardian(s) must currently receive one (or more) of the following: Financial assistance through Ontario Works or the Ontario Disability Support Program in the City of Toronto, Rent subsidy, Welcome Policy or the National Child Benefit Supplement (NCBS).

4 If receiving rent subsidy, Welcome Policy or the National Child Benefit Supplement (NCBS), please include proof with this Application . Include your child's letter/drawing about why he / she would like a computer. If this is not possible for your child, please let us know. Include a reference / supporting letter from an adult who is not a family member. This letter can be from a teacher, principal, guidance counsellor, community worker or other professional who supports the request for a computer. The letter must include the reference's full name and phone number. The child and parent(s) / guardian(s) must sign the Application and mail it back to us Things to Note The child who applies may need to attend computer training sessions. The parent(s) / guardian(s) need to support the child's participation and may have to attend one of the training sessions. The family may need a telephone for Internet connection. Send in only one Application per family. Questions? Call 416-392-8610