Chicago Connected Change of Residency

Chicago Connected at City Colleges - Change of Residency Form

Chicago Connected participants:
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‌If you move homes and need to change where you receive free internet service, please complete the form found below. You can only receive free internet service in one location at a time. If you move and you don’t complete this form, you will not have access at your new location through this program.
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‌Questions? Contact: chicagoconnected@ccc.edu.

Confirmation

Please indicate whether you are the student, at least 18 years old, and completing the form yourself, or whether you are a parent or legal completing the form for the student who is younger than 18 years old.

I am enrolled in City Colleges of Chicago and am receiving existing Chicago Connected no-cost broadband service. Due to a change in my living situation, I need to move the location of my internet service.

NoYes

Service Information

Internet Service Provider

Account Number

Student Information

Student First Name

Student Last Name

Student DOB

CCC Student ID

Phone

Original Address

Original Street 1

Original Apartment/Unit/Suite Number

Original City

Original State

Original ZIP

New Address

New Street 1

New Apartment/Unit/Suite Number

New City

New State

New ZIP

Consent

I provide City Colleges of Chicago with consent to share the above contact information with my internet service provider (either Comcast, RCN, or T-Mobile) to confirm my eligibility for this program and the continuation of service. I also acknowledge that if I need to make a change in my service, I must contact my internet service provider directly and advise that I am a City Colleges of Chicago student enrolled in Chicago Connected.

NoYes

Additionally, as part of my participation, my internet service provider will need to share personal information including my name, address, phone number and account number with the program sponsor, which I authorize to access and use in order for the sponsor to pay the internet service provider on my behalf. By continuing to participate in the Chicago Connected program, I consent to the sharing of my personal information with the program sponsor and it using the information for the stated purpose.

NoYes