Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Phone

(###)

###

####

Do you live *

Alone

With a roommate

With your parents or family member

With a host home provider

In a Group Home or Assisted Living

Do you currently own *

Laptop

Tablet or Ipad

Smart phone

Desktop computer

I do not own any technology

Do you currently receive HCBS waiver services? *

Yes - SLS waiver services

Yes - DD waiver services

No - I don't receive waiver services but I want to

No - I don't receive waivers services and I don't want to

I don't know what waiver services are

Can you make the commitment to attend in-person classes each week for 12 weeks?

Yes

Maybe

No

I'm not sure