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Chromebook Lost/Damaged Form

Please full out the information below and include the total cost to repair/replace your device in the envelope provided.

Replacement/repair will not occur until the associated cost has been paid in full.

Today's Date*

Answer required for "Today's Date"

Student's full name*

Answer required for "Student's full name"

Current grade of student*

Answer required for "Current grade of student"

Please note: There will be no refunds once transaction has been completed.

Name of person completing the form*

Answer required for "Name of person completing the form"

Select the option*

Answer required for "Select the option"

$20.00 - Lost charger

$50.00 - Broken Chromebook

$200.00 - Lost Chromebook

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"

Invalid email address