Request a PC (Phoenix)

We are no longer able to deliver computers due to high demand. All computers must be picked up from our main office where we will provide the training in person and answer any questions the recipient may have. We are a team of all volunteers, and are currently moonlighting this project. Thank you for understanding. For funding opportunities please contact us.

This form is for our Phoenix Chapter, click here for our Tucson Chapter

Feel free to download our request form and email to for our Phoenix Chapter. 

Requester Info:

Name of person filling out this form (if applicable)

Requesting Organization (if applicable)

Requester Phone (if applicable)

Requester Email (required)

How did you hear about us? (recommended)

Family info:

Family Name (required)

Phone Number (required)

Email (if applicable)

Home Address (required)

City (required)

Zip (required)

Primary Language spoken at home (required)

Does anyone in the family speak English? (required)

How long has this family been in AZ? (required)

Does this family have access to their own transportation? (required)
YesNoNot sure

Can this family come into the office and pick up their computer? (required)
YesNoNot sure

Size of Family (required)

Age of Youngest & Oldest Child (required)

Does family currently have internet access? (required)

Does family have prior experience with computers? (required)

What will this family be using their new computer for? (required)

Custom Preferences, Software, Case Manager Contact info, or Comments

By submitting this form, I acknowledge that I understand there is no guarantee a computer will be provided to the Recipient designated above. All computers are provided from currently available inventory and may not be exchanged.

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