Senior iPad Program
Please complete this form for each participant you are requesting an iPad for. One form per person. You will be asked to provide the name of the intended recipient for an iPad in this form. Please do not include any other identifiable information about this person in this form.

This form is only for senior center staff to fill out. If you are a potential receiver of the iPad, please speak to your senior center and they will fill this form in and go through all the logistical steps.
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Email *
Wyoming Department of Health - Aging Division
What is your organization's name? *
This will be the sponsor organization for which the device is paired with.
What is the name of the person you're requesting an iPad for? *
Please provide first and last name.
Does this person have the ability to access the internet via a Wi-Fi connection? *
If no, please be able to explain the benefit of this device in the final questions.
Which Aging Division program will this person and device be counted under with your organization? *
Please describe the intended purpose of the device for this person, and anticipated results of utilizing this device in a long statement that includes most or all of the following areas: level of poverty, health decline, inclusion in group activities, reducing social isolation and geographical location. Please relate it to the Aging Division program it will be counted under... *
Examples could include but are not limited to; supporting older adults who are socially isolated, assisting older adults in ordering food or meals, allowing participant to interact with telehealth services; and assisting in the provision of virtual caregiver supports.
A copy of your responses will be emailed to the address you provided.
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