* Required

Parent/Guardian Information

The person listed in this section will be the primary contact regarding this request and the email will be used for related communications. Please ensure this information is accurate

Parent/Guardian Namerequired

Emailrequired

Phone Number

Preferred Language

Are you an RSD staff member submitting this form on behalf of a family?*

Yes No

Staff Member E-mail

Student Information

Is your student in grade 4 or higher?*

Hotspots will be provided to students in grades 4-12 who take home devices and do not have internet access at home. Please attest your student is in grade 4 or higher.

Yes No

Student First Namerequired

Student Last Namerequired

Student Numberrequired

School required

How many RSD students live in your household?required

Do you already have a district hotspot?*

Students may receive replacement devices if the hotspot is not working. Please indicate if you already have a device that needs replacement.

Yes No

Hotspot Challengesrequired

Please explain the issues you are having with your hotspot. Be prepared to return the old device to swap for a new one.

Please send a confirmation email to the address below*: