SSMS Distance Learning - Device Reservation

Distance Learning is set to begin on Tuesday, March 31st. In an effort to better prepare for our Jaguar families, we are asking that your please fill out the form below if you are in need of a device for distance learning. Devices will be ready for pickup on the morning of Monday, March 30th. Please keep in mind that in order to better serve more families, we are limiting households to 1 device per 2 students.

Student's Name Student's Name First Last
Student's ID Number (Lunch Number)
Student's Grade Level

Student's Grade Level 6 7 8
Second Student's Name (if more than one SSMS student lives in household) Second Student's Name (if more than one SSMS student lives in household) First Last
Second Student's ID Number (Lunch number, if more than one SSMS student lives in the household)
Second Student's Grade Level (if more than one SSMS Student lives in household)

Second Student's Grade Level (if more than one SSMS Student lives in household) 6 7 8
Name of Parent or Guardian Name of Parent or Guardian First Last
Phone Phone - ### - ### ####
Email address of Parent or Guardian
By signing this box, you are agreeing to the Pasco County Electronic Device Agreement. You agree to return the device in the condition in which you received it.Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.