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Have you received a C2K Computer in the past?(Required)

Yes

Does your household participate in any of the following?(Required)

Title 1 School

Free/Reduced Lunch Program

SNAP

Federal Public Housing Assistance

WIC

Lifeline

SSI

Medi-Cal

None of the Above

Please Attach Proof of Program Selected

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Please enter your estimated annual family income(Required)

(To calculate yearly income, multiply weekly income by 52; Bi-weekly income by 26 or monthly income by 12)

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Primary spoken Language(Required)

How did you hear about C2K?(Required)

Are you a member of the Boys & Girls Club?

Yes

Which Club do you attend?

Please indicate the number of people living in the household by age group

Children 0-5 years

Children 6-12 years

Children 13-17 years

Adults 18-24 years

Adults 25-35 years

Adults 36-45 years

Adults 46-55 years

Adults 56-65 years

Adults 66 years and older

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Would you like to speak with someone regarding your declined application?

Yes

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Last Name(Required)

Email(Required)

Phone

Message(Required)

Contact Information

Last Name(Required)

First Name(Required)

Email(Required)

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Do you want to receive an SMS text confirmation once we’ve processed your application?

Yes, I want to receive text updates (By checking this box you agree to receive account updates, news updates, product updates, service updates, event updates, and other notifications from Computers 2 Kids. Message frequency varies. Text HELP to 73064 for help or STOP to 73064 to stop receiving SMS msgs. Msg and Data Rates May Apply. By Opting in, you authorize C2K to deliver msgs using an automatic telephone dialing system and understand that you are not required to opt in as a condition of purchasing any property, goods, or services.)

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Apply for a Computer

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Please indicate the number of people living in the household by age group

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