Connections Program Registration – CoA

Community Connection Program

Welcome to the Registration Page

Please complete the registration form below, at any time up to the closing date (extended to 30th July 2021). We recommend that you do this as soon as you can as  places are limited.

We will then get in touch with you nearer to the closing date.

Thank you.

Registration Form:

Name *

First

Last

Date of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

About your interest in the program

Your responses here will assist us with we how we can best support you. ** Please note: this program will go ahead, even if there is a Covid lockdown or restrictions. We will comply with any requirements and the face-to-face sessions may be replaced by online (zoom) sessions,

What do you hope to gain from this program? *

What do you see as potential limitations for you participating in this program? *

After reading about the program, please list here any questions that arise for you... *

Please ask any questions which will help you better understand the program or how it will work for you

Is there anything to share with us to support your health, wellbeing and safety? *

Please include/describe any support or needs regarding health, wellness, safety or wellbeing that would be important or good for us to know and that will help with our planning.

Is there work or activities that you do in the city of Adelaide (Postcodes 5000 or 5006)? *

Please list any work, volunteering or other activities in which you may participate in these postcodes (Adelaide CBD)

How did you hear about this program? *

This helps us understand how to best reach people.

About your preferences and times to participate in the program

Please tick as many of the options below that you can be available for the monthly face-to-face to sessions. *

• 1:30pm Tuesdays at Adelaide South-West Community Centre
• 6:45pm Wednesdays at the Box Factory Community Centre
• 10:30am Saturdays at North Adelaide Community Centre

You may also provide any other comments regarding session arrangements in the box below:

Paragraph Text

About your contact details

*Note: to be eligible for this free program you must be resident or working/volunteering in postcodes 5000 or 5006. If you live elsewhere and are interested in the program please continue to register.

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

About how you feel using technology

Your answers here will assist us to understand any support needs you may have using technology

How comfortable are you using web browsers? *

• I am good with browsers
• ok, I can get by
• I need help/training

Web browsers include Edge, Safari, Chrome, Firefox, Opera, Internet Explorer

How comfortable are you using zoom? *

• I am good with it
• ok, I can get by
• i need help/training

Zoom is an application that allows you to connect with others using video and audio from your phone, tablet or computer

About the technology you have

Your responses will help us to register you with the online program and provide some support and guidance. **Please use your best guess where you do not know the answer.

Do you have an email address? *

• Yes
• No

What is your Email address *

please provide a valid email address that we can use to contact you.

We will establish a Gmail for you

We will notify you of your Gmail address, to enable communication while you are on the program and also help maintain your privacy.

Do you have a mobile phone? *

• Yes
• No

What is your Mobile Phone Number?

Which Make is your mobile phone *

• Apple
• Samsung
• Google
• Other

How old? *

Age of your mobile phone in years

Data per month available? *

How much data per month in Gb (Gigabytes) is available to your mobile? (Note:if you are not sure, your best guess is ok)

Do you have a tablet? *

• Yes
• No

Tablets include iPad, galaxy rab, yoga etc

What Make is your tablet? *

• Apple
• Microsoft
• Google
• Samsung
• Other

How old? *

Age of your tablet in years.

Data per month available? *

How much data per month in Gb (Gigabytes) is available to your tablet (it may be part of plan to your home)? (Note:if you are not sure, your best guess is ok)

Do you have a Computer? *

• Yes
• No

Computers include desktops/notebooks/laptops; Windows PCs, Surface, Apple Macs/Macbooks etc

Which Make is your computer? *

• Apple
• Microsoft
• Google
• Samsung
• Other

How old? *

Age of your computer in years

Data per month available? *

How much data per month in Gb (Gigabytes) is available to your Computer (it may be part of plan to your home)? (Note:if you are not sure, your best guess is ok)

Submit your registration