ReBoot

Date
Name
Age
Contact Person
Address
City
State
Zip
County
Phone Number
Fax Number
Sex	Female   Male
Race

Are you a DRS Client? Were you a DRS Client? When?

Name of DRS Counselor:

Please describe your disability:

1. Explain why having a computer will help you:
2. Have you tried to obtain a computer from another source? Yes No  If yes, what have you tried?
3. To qualify to participate in ReBoot you must have a training plan.  How ill you learn to use your computer?
4. Would you like to go through computer training? Yes No   How much would you be able to pay an hour? $10  $15  $20 
5. How did you hear about the service?
6. Would you like to be on our mailing list?  Yes No  
7. If your application is approved, do you agree that you are responsible for 20 hours of Volunteer Work?  Yes No  
8. Where will you serve these hours?
9. What Assistive Technology would you need (e.g., keyguard) and how will you obtain it?
10. Would you like to make a donation to help ReBoot continue this service?  Yes No  Amount: $

Additional Comments: