Closed School Student Form

Emily Cooperative Telephone Company and Crosslake Communications will be providing FREE entry level internet service for two (2) months to families with students in the ECTC or Crosslake Communications serving areas that currently do not have services for student online
learning.
This form is for parents and guardians of students (college or otherwise) whose school or university has shut down due to coronavirus
(COVID-19).
This service is for families with students that have not had previous internet service with us. Once approved, this form will allow for two (2) months of FREE entry level internet service.

Customer Information

Parent or Guardian First Name *

Parent or Guardian Last Name *

Last 4 of SSN (for account verification): *

E-911 Street Address *

City *

State *

Zip *

Different Billing Address? *

Yes

Billing Street Address

Billing City

Billing State

Billing Zip

Phone *

Email *

Student Information

Student #1 Name *

Student # 2 Name

Student # 3 Name

Student # 4 Name

1. Name of closed school your student(s) attends in the ECTC and Crosslake Communications Serving area: *

2. Name of closed school your student(s) attends in the ECTC and Crosslake Communications Serving area:

3. Name of closed school your student(s) attends in the ECTC and Crosslake Communications Serving area:

4. Name of closed school your student(s) attends in the ECTC and Crosslake Communications Serving area:

What is the current known date school will re-open? *

Name of Closed University your student(s) attend:

Please upload a copy of the students' current student ID card or recent report card with school name. *

Maximum upload size: 516MB

By typing and signing your name below, you agree this is an electronic signature. You also agree that the student(s) name you submit does live in your household.

Name *

Date *

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