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CONTACT INFORMATION:

NAME *

First Name

Last Name

ADDRESS *

PHONE *

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EMAIL *

PREFERRED METHOD OF CONTACT *

PREFERRED LANGUAGE *

AVAILABILITY *

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

WHICH DEVICES DO YOU OWN? *

COMPUTER TOWER

LAPTOP

TABLET

SMART PHONE

NONE OF THE ABOVE

HOW COMFORTABLE ARE YOU WITH TECHNOLOGY? *

VERY COMFORTABLE

SOMEWHAT COMFORTABLE

NEUTRAL

SOMEWHAT UNCOMFORTABLE

VERY UNCOMFORTABLE

WHAT WOULD YOU LIKE TO USE TECHNOLOGY FOR THE MOST? *

WHICH SERVICE ARE YOU MOST INTERESTED IN? *

HOW DID YOU HEAR ABOUT TECH SENIORS? *

GOOGLE

FACEBOOK

INSTAGRAM

LOCAL ADVERTISEMENT

FRIEND OR FAMILY

WORKSHOP

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