Registration Application

Registration, Assessment and Waiver Form must be completed before submission.

Level of Education

Which courses would you like to take?

Are you retired?

Yes No

Current Employment Status

Employed Unemployed Underemployed

What types of digital devices do you own?

On a scale of 1 to 10; how comfortable are you with technology?

** There is no charge for registration for classes. Registration & Assessment Form must be completed before registering. If you have questions, please call us at 610-639-6737. **

Choose all that apply.

Do you currently have an email address?

Yes No

Do you have available internet?

Yes No

Do you keep track of your passwords and user ids?

Yes No Sometimes Very Seldom

Are you comfortable using the internet?

Yes No

Do you have access to internet service in your home?

Yes No

Do you have a back-up for your computer and all digital devices?

Yes No

Name of other back-up system:

What are three things you'd like to learn how to do on your Smartphone or Computer?

First Thing You'd Like to Learn

Second Thing You'd Like to Learn

Third Thing You'd Like to Learn

Are you comfortable with technology terms & symbols?

Yes No

Do you have any mobility problems that interfere with your use of computers?

Yes No

The Following Information is Required to Complete Registration

I, a participant of Technology & Computer Classes or participants of the Workshops offered by Senior Lift Program”, I hereby give my permission to be photographed, filmed, videoed, or interviewed by President, Board of Dir. and staff members of Senior Lift, (a non-profit 501c3 entity). In signing this form, I hereby release any and all actions and claims which I, my family members, our heirs, executors or administrators may have against the Senior Lift, (Nonprofit) This release applies to each and any of Senior Lift’s contractors, staff, board members, and/or Senior Lift and its employees, representatives, agents, successors and assigns, arising for any reason whatsoever from the use, publication, distribution or republication of the images and/or words gathered during this event/activity. I warrant that I am at least 18 years of age and acknowledge that I have thoroughly read, understand, and I agree with the working displayed in this Waiver and Release Document.

To agree to these terms please check this box.

Registration and Assessment Forms

Registration

Assessment

Waiver

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