Goodwill Connect Intake Form

Today's Date*

MonthDayYear

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Primary Contact Number

Phone Number

Secondary / Message Number

E-mail

example@example.com

Preferred Method of Contact*

Birth Date*

MonthDayYear

Gender*

Ethnicity*

What Languages Are Spoken In Your Home? (Choose all that apply)*

Other Language Not Otherwise Listed

Do you need any accommodations? (Choose all that apply)*

Other Accommodation Not Otherwise Listed

How Can We Help You Today? (Choose all that apply)*

Other Assistance Not Otherwise Listed

How did you hear about us?*

Do you have access to a computer?)*

How would you rate your computer skills?*

Are you receiving Medicaid?*

How many people are you economically responsible for in your household? (Including yourself.)*

What is your monthly income? (NOT COUNTING any State or Federal assistance/benefits)*

Terms and Conditions

Please note, if eligible you will be required to attend a device gifting orientation. Another person may not pick up the Chromebook on your behalf. We will get in contact with you to schedule a date and time for your orientation.

We will attempt to contact you on three (3) separate occasions via your primary phone, secondary phone, and/or email. If we are unable to get ahold of you, or you do not respond with a call back, you will be marked, "Unable to Contact" and you will be unable to receive a Chromebook.

When scheduled for a device gifting orientation, we ask that you arrive early or on time. If you arrive more than 15 minutes late, you will forfeit your spot at that orientation and marked as a No Call No Show and you will not be able to receive a device gifting at that event.

After three (3) No Call No Shows, you will lose your Chromebook and be deemed ineligible for the device gifting program. However, you will still be eligible to receive other Goodwill Services.

IMPORTANT: This program is intended to distribute (1) device per household. Any attempt to apply multiple times by using a different name, phone number, or address will be considered intentional fraud; this will remain in your record, and you will be marked ineligible for the Goodwill connect program across the State of Washington.

It is understood that the information provided above and obtained through this intake form will be treated with the strictest confidentiality. This release will be in effect for one (1) year from the date signed unless terminated in writing earlier by myself, the undersigned participant.

Signature*