Digital Connections Interest Form | Sourcewise The Sourcewise Connections, Health, Aging & Technology program

Sourcewise Digital Connections Program Interest Form

Thank you for your interest in the Digital Connections (DC) Program. Sourcewise is excited to offer the program to help bridge the digital divide gap and address social isolation. The program is free to eligible seniors and caregivers to seniors ages 60+ and is provided in partnership with the California Department of Aging. Once eligibility is confirmed, program participants will receive an iPad to use for a limited time, coupled with training and general technical support. Devices are limited and available while supplies last. If you are interested in the program, please fill out this brief interest survey below. If you require translation assistance or would rather fill out the survey over the phone with the help of a coordinator, please call (669) 699-2245. If you qualify, someone from our team will contact you to complete a required enrollment form and program survey before receiving your tablet. This program is also open to caregivers as well but will prioritize caregivers that fit the other eligibility requirements. If you’re a caregiver and would like a tablet for someone you care for (older adult 60+ years), we recommend that you do the survey process together to confirm they consent to the program enrollment and requirements. You may contact our office at any time if you have questions or comments. You can email us at tech@mysourcewise.com or call at (669) 699-2245.

An informal caregiver is defined as someone taking care of an older adult or adult with a disability." Are you an informal family caregiver? *

Caregiver Name *

First

Last

Caregiver Phone

Caregiver Email *

Do you live with the individual whom you are applying for? *

Senior Name *

First

Last

Senior Email

Senior Phone Number *

Senior Address *

Senior Zip Code *

Senior City *

Senior Date Of Birth *

Select your Income Level per Month: *

What language do you feel most comfortable speaking? *

Other Language

What other languages are you comfortable speaking?

Other Language

Do you live alone? *

Do you have home Wi-Fi that is working? *

Please check any of these devices that you have in your home. More than one answer is accepted. *

Desktop Computer
Laptop Computer
Tablet, e.g. iPad
Smart Speaker, e.g. Alexa, Google Home, Siri
Landline or Cell phone
I have other technology that helps me with daily activities, (please specify)
I have none of the above

Other Technology

On the scale of 1 to 10 below, how comfortable are you with learning new technology? 1 is very uncomfortable; 10 is very comfortable. Slide the circle.

Selected Value: 0

To participate in this program, you will need to participate in a total of 2 to 3 research sessions (30 mins to 1 hour each) before and after receiving the device. This involves asking you questions over the phone. If at any time you are uncomfortable, you may decline to answer. Are you willing to participate in these sessions? *

Please check the services below where you would like to receive more information. *

Other Services

How did you find out about this DC program? *

Other

Sourcewise Digital Connections Program Interest Form

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