Tech Member participant registration and agreement

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We will contact you in a few days and, if accepted onto the project, we will then arrange delivery of the device and training and ongoing support. If you require help completing this form, please use the contact details on the rear of this form.

Please fill in this form if you are interested in joining the project and being loaned a tablet computer and training and support to use it.

Tech Member registration and agreement form

Your Name(Required)

Gender(Required)

Email address (if you have one)

Address - Borough(Required)

Sorry - this service is unavailable for your area

Unfortunately due to funding restrictions, we’re not currently able to offer the service in North West Surrey. If you require support in this area, please get in touch with the Digital Buddy Scheme: Digital Buddy - Surrey County Council (surreycc.gov.uk)

PLEASE DO NOT CONTINUE TO FILL IN THIS FORM

Your details

Address(Required)

Postcode(Required)

Your Date of birth(Required)

Telephone number(Required)

Preferred method of contact

Telephone

Post

Please let us know your preferred language for written communications. (We aim to translate our SMS (text) communications to your preferred language.)

Do you have a computer, a smart phone or a tablet computer already?(Required)

Yes

Do you have WiFi connection where you live?(Required)

Yes

Are you in receipt of any means tested benefits? (that would entitle you to a cheaper broadband plan from BT)(Required)

Yes

Do you live on your own?(Required)

Yes

Emergency contact information (for example, a family member, a carer or a good friend)

Emergency contact name(Required)

Emergency contact telephone number(Required)

Please pick as many as required(Required)

Other

Which of the following best describes you(Required)

I am currently shielding because my health condition makes me extremely vulnerable to Coronavirus

Yes

I am an unpaid carer/family member

Yes

I am interested in joining Surrey Coalition of Disabled People

Yes

How did you hear about us?

Would you like to sign up to our Coalition newsletter and receive our Weekly Update by email?

Yes

Your Data Organisations need to store and sometimes share your information, Please read and tick these statements below if you are happy for us to securely use your data.

I give permission for Surrey Coalition of Disabled People to store and use my personal data with the intention of coordinating my involvement in the Tech to Community Connect project and that they will treat my data in accordance with General Data Protection Regulation guidelines at all times.

I give permission for my details to be added to the Surrey Coalition e-mailing list so that I can be sent a regular newsletter

Message

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