COVID-19 Electronic Device Grant

Name(Required)
Address
What is your sickle cell status?(Required)
Relationship with applicant
Max. file size: 256 MB.
MM slash DD slash YYYY
Do you have a working electronic device?(Required)
Have you attended SCAGO webinars in the past?(Required)
Will you attend COVID-19 and other educational sessions if given a device?(Required)
Have you been vaccinated?(Required)
I hereby verify that all information provided on this form is true(Required)