Beta Tester Enrollment Application

Beta User Enrollment Application

Thank you for your interest in the Keep Safe 911 Beta User Program. Please complete the questionnaire below to be considered.
Applicant information
Applicants Name*

First NameLast Name
Date of Birth - must be over 18 years old*

MonthDayYear
Date
Age
Email*
example@example.com
Primary Phone Number*
Format: (000) 000-0000.
I'm a parentI'm an uncle/auntI'm a grandparentI'm a foster parentOther
YesNo
ClubhouseFacebookInstagramLinkedInSnapchatTik TokTwitterWeiboYouTubeOther
Please share your social media handle(s).
Ability to helpBullyingRacial disparity/inequalitySafety issues at schoolStranger dangerTraffickingOther
How did you hear about us?*
Your equipment and software
YesNo
What phone model do you have?
Your technical abilities
How confident are you using your phone (ex: screen captures, manage Google play store and app settings)?*

1

2

3

4

5

6

7

8

9

10

1 is Not confident, 10 is Very confident
YesNo
Beta tester requirements
YesNo
YesNo
YesNo
YesNo
By signing below, I acknowledge the agreement stated in this form. I also confirm that all information I entered in this form is true and accurate.
Applicant Signature*
Date Signed*

MonthDayYear
Date
Hour Minutes
Should be Empty:

Beta User Enrollment Application