LEAP grant application

Discover if you or your clients are eligible for discounted or free technology through our LEAP program. Agencies working with resettled students and families are encouraged to apply, as well as former refugee/resettled individuals and families experiencing financial need who do not have access to a home computer. Applicants may apply themselves, through their case-worker, or through a resettlement organization.

Date:

Referring organization (if any)

Contact person for referring organization (first and last name, e-mail address):

First name of applicant:

Last name of applicant:

Applicant's home address:

Applicant's apartment complex (if applicable):

Applicant's county (e.g. Kent, Ottawa, etc.):

Applicant's e-mail address:

Applicant's phone number:

Applicant's date of birth (M/D/Y)

Please list the other members of the applicant's household, including ages and schools attended, if applicable:

Is the applicant a current or former refugee?

What is the applicant's country of origin?

Is the applicant a student or involved in job/career training?

Is the applicant enrolled in GED, ESL, or ESOL classes? If so, through which school or organization?

Applicant's annual household income range:

i.e. <$10,000, $10,001-$20,000, etc.

Which, if any, of the following programs has the applicant participated in?

Unemployment or Workman's Comp Benefits
Social Security Disability Insurance (SSDI) Benefits
Michigan BRIDGE Card - Food Assistance Program
Michigan BRIDGE Card - Cash Assistance Program
Michigan Women, Infants and Children (WIC) Program
Medicare
Medicaid
Section 8, HUD's Public Housing Program, or other subsidized living programs
Free or reduced school lunch programs
MDHHS Child Care Assistance

Does anyone in the applicant's household currently own a computer?

Yes
No

Does the applicant have internet access in his/her home? If so, through which provider?

Please tell us why the applicant individual or family is in need of a computer:

Is there any other information you would like to include with your application?

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