Request edit access
Digital Navigator Intake Form

Fill out this form to request free tech help/digital navigation services. We can assist with internet access, devices, digital skills, group workshops and more.

We typically respond within 24 hours. Please note we do not work on weekends or federal holidays and we are unable to provide in-home visits.

Privacy Notice: Your personal information will be kept confidential and is only used by the United Way of the Franklin and Hampshire Region to provide you with digital navigation services. We do not share, sell, or distribute your information to outside organizations. Your privacy is important to us, and we’re committed to using your information solely to better support you.

Sign in to Google to save your progress. Learn more
Community Member or Organization Name *
Zip code
What is the best way for me to contact you?
Primary Contact (phone/email)*:
 *
Email
What language(s) are you comfortable communicating in?
Preferred days & times to meet (e.g. Mondays before noon, etc.)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
9am-12pm
12pm - 2pm
2pm - 5pm
How did you hear about this program? 
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of United Way of Franklin & Hampshire Region.

Does this form look suspicious? Report

Google Forms