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 *YesNoAre there specific challenges you face in your daily life that having a smart device could help address? *What kind of technology skills or experience do you have? *Are there specific tasks or activities where you think a smart device would be particularly helpful? *Would you appreciate follow-up support or training after receiving the smart device?YesNoDo you have someone who can help you set up and use the smart device?YesNoDo you have any visual or hearing impairments that we should be aware of?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
