Program Date *

MM

DD

YYYY

Your Name *

First Name

Last Name

Your Phone Number

example: 704-999-9999

(###)

###

####

Your Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is your current Employment Status? *

Employed full-time

Employed part-time

Unemployed

Self-employed

Retired

Prefer not to say

Have you previously taken a Senior Planet Digital Skills Ready@50+ Class? *

Yes

No

Age Range? *

under 50 - 54

55 - 59

60 - 64

65 - 69

70 - 74

75 - 79

80+

Prefer not to say

Gender *

Male

Female

Non-binary

Prefer to self-describe

Prefer not to say

Race / Ethnicity *

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

Multi-racial

White (non-Hispanic / Latino)

Prefer to self-describe

Prefer not to say

Are you of Hispanic, Latino, or Spanish origin or descent? *

Yes

No

Was your household income more than $32,000 last year? *

Yes

No

Generally, how often do you use the internet on a digital device? *

Daily

A few times a week

Monthly or less often

I don't access the internet

Do you currently have internet access at home? *

Yes

No

Not sure

How comfortable are you with using a computer/laptop/tablet? *

Not comfortable

Slightly comfortable

Moderately comfortable

Very comfortable

How comfortable are you with using a smart phone? *

Not comfortable

Slightly comfortable

Moderately comfortable

Very comfortable

Fill My Cup! COVID-19 Event & Program Disclosures/Disclaimers/Wellness Policy *

By registering with Fill My Cup! a Licensed Partner for this Digital Skills Ready@50+,™ from AARP offering, I hereby acknowledge and agree that: The dates, locations, times and format of this offering are subject to change due to Fill My Cup! being a Licensed Partner of Digital Skills Ready@50. I assume all risk in connection with participating in this offering and understand that the COVID-19 remains a threat to individuals and public health and that COVID-19 is a highly contagious disease. I release, discharge and hold harmless Fill My Cup!, the entity location hosting the training, and Digital Skills Ready@50+™, Senior Planet, from AARP and its affiliates, and their respective, employees, independent contractors, directors, officers, volunteers, vendors and agents from and all liability, claims, and demands of every kind. If I am asked to leave this offering by Fill My Cup! the Licensed Partner of a Digital Skills Ready@50+™, Senior Planet event or program from AARP representative upon the belief that I am exhibiting COVID-19 or flu symptoms, I will immediately comply with that request and leave the offering premises.

Agree

COVID-19 Wellness Policy *

For the safety of all, upon entering the training area, masks and hand sanitizing are requested. Social distancing will be used as available. Please remember that if you are experiencing any allergy, cold, or flu-like symptoms, or if you are waiting for a COVID test result, we ask that you not attend any Fill My Cup! event or program. Please read our COVID-19 protocols. It is our hope to try and keep everyone safe, as we attend trainings, events and programs. We ask that you adhere to these safety measures. If you can answer YES to any of the following questions, please DO NOT attend the training. (please contact our Fill My Cup! office at (704)705-9797 to reschedule at the appropriate time

Agree

Have you have traveled outside of North Carolina in the last seven (7) days and you are not fully vaccinated? *

Yes

No

Have you traveled outside the United States in the last seven (7) days? *

Yes

No

Have you have taken a COVID-19 vaccine and are presenting COVID-19 or flu-like symptoms? *

Yes

No

Have you have come into direct contact with anyone with COVID-19 or are you are waiting on a COVID-19 test result? *

Yes

No

Are you are presenting any flu-like or allergy symptoms or do you have a fever? *

Yes

No

Signature Date *

MM

DD

YYYY