Access Technology – IC Future

Do you currently have internet?/¿Actualmente tienes internet? *

Yes/Si
No

Name/Nombre *

First

Last

Primary Language/Idioma *

English
Spanish
Other

Do you have a cell phone?/¿Tienes un telefono celular? *

Yes/Si
No, I only have a landline./No, solo tengo un telefono de casa
Third Choice

Phone Number *

Email

Street Address *

City *

State *

Zip Code *

Government Assistants/¿Asistencia de Gobierno? Check all that apply. *

SNAP, EBT food stamps, and CalFresh provide assistance in purchasing food for the home. Medi-Cal is health insurance provided by California. Supplemental Security Income is government program that provides stipends to low-income people who are aged 65 or older. Social Security program that pays monthly benefits to you if you become disabled before you reach retirement age. National School Lunch Program is free or reduced meals at school. Public Housing Assistance and Section 8 vouchers provide assistance with affordable housing. Lifeline Program that provides free or low cost phone service

How did you hear about us? *

Please confirm if you would prefer to be contacted back via text. A representative will respond back as soon as possible. Only select Phone Call if you are unable to communicate with us through text. Por favor, confirme si prefiere que nos contactemos con usted por medio de mensaje de texto. Solo seleccione Llamada telefónica si no puede comunicarse con nosotros por mensaje de texto.

Text message / Mensaje de texto
Phone call / Llamada telefonica