Smart Device Application Form

Apply for a smart device

Name *

First

Last

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Age *

Ethnicity *

Gender *

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). *

i have a smartphone *

i have access to the internet *

I 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. *