• Technology Services Application

    If you have questions while filling out your application, call Technology Services at 952-888-5530.

  • THIS IS NOT AN APPLICATION TO RECEIVE CHORE HELP THROUGH THE HOME PROGRAM. If you would like to apply for the HOME Program, click here to be taken to the correct form.

  • First, let's check if you are eligible for services.

  • Are you 60 or older?*
  • Do you live in our service area: Hennepin, Wright, Sherburne, Scott, Ramsey, Anoka, or Carver County?*

  • Unfortunately, you do not qualify for services at this time.

    We have a list of Technology Frequently Asked Questions on our site covering the basics of internet and device access, smart phones, smart TVs, and more. Click here

    Senior Planet from AARP may also be able to help. Click here or call their hotline at 888-713-3495.

  • Client Information

  • Date of birth*
     - -
  • Gender*
  • Ethnicity*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?*

  • Veteran and Disability Status

  • Are you a veteran of the U.S. Military?*
  • Do you have a physical disability or mobility challenge we should be aware of?*

  • Emergency Contact Information

    You must supply an emergency contact to continue this form.
  • Format: (000) 000-0000.

  • Please tell us about your living situation and monthly income.

  • Do you live alone or with others?*

  • Additional Person in Household

    Please fill out this information for the additional person in your household.
  • Date of birth*
     - -
  • Gender*
  • Ethnicity*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Veteran and Disability Status

  • Is this person a veteran of the U.S. Military?*
  • Does this person have a physical disability or mobility challenge we should be aware of?*

  • Use of Information Statements

  • I understand that the information I am providing on this form is for registration purposes. I certify that the information provided on this form is accurate and complete. I authorize Senior Community Services to verify this information, if necessary, and to provide this form to governmental entities as a condition of funding they provided to this agency. This information will not be released to anyone other than the above mentioned parties in a way that will identify me as an individual unless I sign a separate consent for that purpose.

  • Applicant Signature

  • Date*
     - -
  • I would like to receive Senior Community Services' email newsletters.*
  • Would you like a follow-up call from the Technology Services team when we receive your application?*
  • Should be Empty: