Technology Services Application

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.
YesNo
I live in one of these countiesI do not live in one of these counties

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.

Additional Person in Household

Please fill out this information for the additional person in your household.
Name*

First NameMiddle InitialLast Name
Date of birth*

MonthDayYear
Date
MaleFemaleOther
Race*
Hispanic/LatinoNot Hispanic/Latino
Main Phone Type*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Type
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Veteran and Disability Status
YesNo
YesNo
Please describe:

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
By typing your full legal name, you are providing a digital signature for this application.*

First NameLast Name
FROM (field for internal SCS use)
Date*

MonthDayYear
Date
YesNo
Should be Empty:

Client Information