Registration FormCongratulations!! Service is available in your area. Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Are you a senior citizen? Yes No Are you employed? * Yes No Do you have health insurance? * Yes No Choose a Service * You May Qualify For More Than One Service Make a Selection Free Smart Phone Free Tablet Free Home Internet Free Health Insurance Benefits you qualify for (check all that apply) * My child attends a CEP (Community Eligibility Provision) school EBT/Snap/Food Stamps SSI (Supplemental Supply Income) Medicaid Veterans' Pension FPHA (Federal Public Housing Assistance) WIC Child or dependent participates in free or reduced school lunch Received a Federal Pell Grant in the current award year I want to qualify using my W2, 1099, tax return, or retirement benefits letter Household Size * Make a Selection 1 2 3 4 5 6 7 8 or More Who is your current internet provider? Make a Selection I currently don't have internet. AT&T Frontier Spectrum Xfinity Other Thank you for your submission!