Apply for a smart device Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *Address *Address Line 1CityState / Province / RegionPostal CodeAge *Ethnicity *Gender *Communication *In order to understand the impact of our grants and how we can help others, please tick box so we can contact you regarding how we have assisted.Proof of identity *Tick box to confirm you will provide ID if selected for this project.I hereby consent to Aishah Help using images of myself caught in video recordings, and/or photographs, taken/recorded (we will not show face if requested). *YesNo i have a smartphone *YesNo i have access to the internet *YesNoI confirm that the information I have supplied is true and correct to the best of my knowledge. I understand that any false or undisclosed information could result in the closure of my application for assistance. *Yes Submit