Individual Laptop Needs Assessment Form

PLEASE READ BEFORE COMPLETING THIS FORM.

This document contains confidential information and will not be duplicated, transferred, or shared.
Individual must be a resident of Los Angeles County to be eligible to receive a laptop.
Individual must have an email address and be able to access that email from a phone or have access to a printer.
Individual can show Recipient ID from a phone or print and bring a copy if approved.
Individual can create, access and print email at a local LA County Library.
Only one (1) laptop per eligible household.
All areas of this form must be completed to determine eligibility.
Incomplete or illegible forms will result in disqualification.

A parent/guardian must complete this form on behalf of a minor under age 18.

I would prefer to recieve email correspondance in Spanish.

1. Event:

Empower Generations Distribution - Wednesday, October 23, 2024

2. Is the person requesting a free laptop currently under the age 18?

Yes

3. Enter contact information of the person requesting a free laptop:

First Name:

Last Name:

Email:

Phone Number:

Check if Applicable:

Temporarily Unhoused

Transitional Shared Housing

Assisted Living

Street Address:

Apt/Unit:

4. Race/Ethnicity (Check All That Apply)

African American / Black (Non-Latino/a/x)

Asian-American

Hispanic / Latino/a/x

Native American / American Indian

White (Non-Latino/a/x)

Pacific Islander / Native Hawaiian

Decline to State

5. Need for Device

6. Does someone in your household currently receive any of the following federal, state or county benefits? (Check All That Apply)

Federal: Medicare, Pell Grants, Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), In Home Support Services (IHSS), Veterans Disability Benefits, Veterans Retirement Benefits, Federal Lifeline Program

State/County: Medi-Cal, Cal-Fresh, Supplemental Nutrition Assistance Program (SNAP), General Assistance (GA), General Relief (GR), California Alternate Rates for Energy (CARE), California LifeLine, California Work Opportunity and Responsibility to Kids (CalWORKs), Unemployment Insurance (UI), Section 8 Housing Choice Voucher Program, Special Supplemental Nutrition Program for Women, Infants, Children (WIC), or BREATHE

No one in my household receives federal, state or county benefits.

7. Upon approval, a Recipient ID will be sent to the email address provided.

Be prepared to show the Recipient ID on your phone or bring a printed copy to pick up one laptop.
Do not share your Recipient ID.
Your Recipient ID can only be used once. If your Recipient ID has already been used at time of pick up or if you are unable to pick up a laptop by the end of the event, the opportunity to receive a free laptop will be forfeited.

8. Self Attestation (Must be checked to submit)

I declare under penalty of perjury that the foregoing is true and correct.

9. Liability Waiver for Receipt of Device (Must be checked, signed, and dated to submit)

By accepting a device from County of Los Angeles, I acknowledge and agree I am receiving the device(s) as part of the DELETE THE DIVIDE Initiative. The use of the device(s) is solely at my own risk. I understand that the device(s) are provided by the County of Los Angeles on an “as is” and “as available” basis. I assume all liability associated with the use (including internet usage) and disposal of the provided device(s). I release the County of Los Angeles and any relevant community partners from all loss, damages, or liability arising out of or relating to my use of the device(s), including, but not limited to: (a) loss or corruption of data, (b) loss of or damage to software or hardware, (c) access delays or access interruptions, (d) computer viruses, (e) non-delivery or misdelivery of data, (f) the negligent acts and/or omissions of the user, (g) lost profits or revenues, (h) business interruptions, and (i) loss or liability resulting from acts beyond the County of Los Angeles' control. I agree to defend, release, indemnify, and hold the County of Los Angeles, and its respective falseicers, falseicials, employees, agents, authorized representatives, and subcontractors harmless from all liabilities, claims, and expenses, including without limitation reasonable attorneys' fees, arising from my use of the device(s).

I certify that I have read this document, and I fully understand its contents and that the information I have provided is true and correct. I understand that this is a liability waiver and release and that I am signing this document freely and voluntarily.

E-Signature (Type your full name)

Date