Service Request Application

Date: Client Information

First Name: Gender: Ethnicity: Last Name Birth Date:

Contact Information
#1 Guardians First Name: Last Name:

Street Address: City: Home Phone: #2 Guardians First Name: State: Cell Phone: Last Name: Zip:

Street Address: City: Home Phone: State: Zip:

Cell Phone: Explain briefly. Use additional sheets if necessary.

Disability:
By filling out the above application, you guarantee yourself to a refurbished computer every two years from The Buddy Project. This application is also used to track maintenance and repairs, if you should need any on the PC you receive. The Buddy Project provides new and used PCs to those who are intellectually and developmentally disabled. People with intellectual, developmental and some physical disabilities have limited access or shy away from technology due to their limited knowledge. We are determined to provide people with intellectual and developmental disabilities better access to the technology that is available today. Continuing to make people with intellectual and developmental disabilities more independent in the community!

Please mail completed application to: The Buddy Project 2107 Chestnut Lane Frederick, MD 21702