HOME CONNECT REFERRAL

Recent events have shown us how important it is to have home Internet access and Community Tech Network wants to support our senior learners in getting the connectivity they need to avoid feeling isolated and to access essential services. Home Connect is CTN’s newest COVID-19-inspired program, designed to connect isolated seniors to the Internet and leverage its resources from the comfort and safety of their home. The Home Connect program will connect senior learners directly with a trained instructor to support them in areas customized specifically for that learner.

This assessment will help us better understand the connectivity needs of our older adults in San Francisco so we can work on getting everyone connected to the Internet, a device and digital skills. Data for this survey is meant to be collected by a senior center staff member who is well known and trusted by the senior they are interviewing. Questions about this project can be directed to homeconnect@communitytechnetwork.org.

*Required

*First Name:
*Last Name:
Street:
City:
*Country:
State/Province:
Zip:
*Phone:
*Date of Birth (mm/dd/yyyy):
Gender Identity:
*Preferred Language:
Marital Status:
Ethnic Identity:
Disability Status:
Sexual Orientation:
Living Status:
Veteran Status:
Federal Poverty Guidelines ?:
Check if your referral has existing internet access:Wifi Password?:
ISP:
*5 Hour Commitment:
Smart Phone:
Digital Device:
Connected Device Skill Level:
Referring Organization:
*Name of Interviewer:
Interviewer eMail: