Shabazz City High School
1601 N. Sherman Ave.
Madison, WI
53704

http://www.madison.k12.wi.us

shabazz@madison.k12.wi.us

FAX:  608-204-0503



First Name:					Last Name:

Street Address:

City:				State:			Zip:

Age of Primary user this machine is intended for (all ages are acceptable, this helps us choose appropriate software for the intended user based on what we have at the time) :

Home Phone number : 				Work Phone number:


Cell:	(cell phones are not always accessible for us to call on our school phone system)

Computer Platform Requested:	Macintosh		Windows		Either


Please fill in this information: circle one

Have you used a computer before?	Yes	No
My hardware experience equals:	1	3	5	7	9	10
My software experience equals: 	1	3	5	7	9	10
My printing experience equals: 	1	3	5	7	9	10

ECAP was designed by students at Malcolm Shabazz City High School in 1998. They believed that anyone not having access to computer technology was not able to prepare for a successful future and that they could take action in this matter by providing computers - free of charge - to anyone not already having a computer.  We have given away 302 computers as of June 2003.  We obtain our computers through donations by area businesses and individuals.

Our primary mission is to provide computers to students, individuals and families to promote educational and career opportunities.  This computer set up is intended to offer word processing, database, spreadsheet, drawing, shareware games and successfully print.  It is not intended for Internet use..

Shabazz cannot provide ongoing technical support or training for this computer system when you receive it.  We have configured and tested it before giving it to you and all parts are in working order. Some machines may have a modem to be hooked up and may be ABLE to be put on the Internet, however, ECAP can not assist you in this


We work on a "0 budget"; meaning we are given no funding to continue this program.  If you have resources such as businesses or contacts that could be donating decent (see web page donation standards for what we currently accept) computers, please share this information with them and direct them to our web site and school.  If you have the ability to donate cash to this program, even $10 or $20, it will place more computers in homes instead of the local dump.  Typically, when there is a machine that needs repair it takes 2 machines to get one functional.   There is no obligation to donate or share our program with others.  We are still glad to be able to offer you a computer for your use and advancement.

If you agree to the following, please sign below and fax, email or snail mail this document to our school.

I will take good care of this equipment.  I will not return it to Shabazz but instead pass it on to others who need it.  I understand that Shabazz cannot assist me with my computer problems once I receive the computer.  I will take responsibility for replacing consumable parts such as printer ribbons or ink, paper, etc.


Signature					Date: