New Customer Registration Form

We want to hear from you! The Community Building Institute has partnered with Spectrum and the City of Middletown to launch a new program to help seniors in Middletown stay connected, safe, and confident using technology. This short survey will help us understand what classes, tools, and support would be most useful to you—whether that’s learning telehealth, social media, email, or everyday apps.
Full Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
What is your gender?*

MaleFemalePrefer to not to answer
Please answer each question below: We’d Love Your Feedback on Senior Technology Classes & Events
1. Which topic below would you like to learn more about? (check all that apply)*

Online safety & avoiding scams/fraudsPasswords & account securityUsing email and attachmentsBasic smartphone use (calls, texts, apps)Video calling (Zoom, FaceTime, WhatsApp)Social media (Facebook, Instagram, etc.)Online shopping & banking safelyUsing health portals (doctor visits, prescriptions)How to use appsNone

2. Which devices below do you use most often, and how comfortable do you feel using them?*

3. How do you prefer to learn?*

In a class groupOne-on-one helpPrinted step by step instructionsOnline video tutorialNone
4. What dates and times are best for you to attend classes or events?*

Weekday morningsWeekday afternoonsWeekday eveningsNone
5. Do you need transportation assistance to attend classes or events?*

Yes, I would need transportationNo, I don't need transportationMaybe, depending on the locationNone
6. Is there anything else you would like to learn or share with us about technology, cybersecurity, or other topics that would help us design classes for you?*
Should be Empty:

Please answer each question below: We’d Love Your Feedback on Senior Technology Classes & Events