Older Adult iPad Application: Access to Technology

At this time the iPad Application is only available for Older Adults residing in Districts 3.

To verify which District you reside in, visit https://ocvote.gov/findmydistrict

Thank you for submitting this short application. Your responses will help determine if you qualify for the iPad Program.

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* 1. Please provide your first and last name.

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* 2. Please provide your date of birth.

Month/Day/Year

Date

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* 3. Are you an older adult (60 years or older)?

Yes

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* 4. Please provide your phone number.

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* 5. Please provide your email.

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* 6. Please provide your complete home address.

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* 7. Please provide just your home zip code.

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* 8. Please provide a secondary contact person.

First Name, Last Name

Phone Number

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* 9. Do you have an income of less than $75,000?

Yes

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* 10. Do you currently own any other technology device (tablet, desktop computer, laptop)?

Yes

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* 11. What is your preferred language?

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* 12. Will you need a translator?

Yes

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* 13. Please check the boxes below that describe you. Please choose all that apply.

I live alone

I live in a care facility

I have a health issue(s)

I have limited mobility

I have a functional disability

I have limited English skills

Other (please specify)

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* 14. If approved, will you be able to pick up the device from the Office on Aging located in the city of Santa Ana?

Yes

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* 15. Did you have assistance in completing this application?

No, I applied myself

Yes, I had assistance completing the application

Yes, the Office on Aging staff assisted

Thank you for your application. You will be notified via phone call of the next steps within 5-7 business days. Please click Submit button below and close the page.