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Senior Connects Method of Teaching and
Computer Literacy Avocation Application
APPLICANT:
Name ___________________________________________________
Address ___________________________________________________
Home Phone __(_____)____________ Other Phone __(____)____________
Cell Phone __(_____)____________ Parent/Guardian’s Name __________
Email ________________@__________________________________
Date of Birth ____________ Name of School ______________________
Password ____________________________________________________
Note: We will release all of your information that you provide to those Independent
Living Facilities requesting information about you and providing us
your password - so please keep your password confidential. When you
give your password to an Independent Living Facility, we know that
you have given your permission to allow us to release any information
that you have provided. We release all information to your parents
(or guardians) and mentors upon their request without a password.
MENTOR:
Name ___________________________________________________
Address ___________________________________________________
Home Phone __(_____)_____________ Work Phone __(____)___________
Cell Phone __(_____)_____________ Date of Birth __________________
Email ________________@_________________________________
Relationship to Applicant _______________________________________
Note: a mentor is required for those applicants that are under 18 years of
age. If you are 17 years of age or younger, a mentor can be a parent,
teacher or a friend of yours that is over 18 years of age and that
you and your family know and trust. If you are 18 or older and choose
not to use a mentor, please complete the above using your parents’
or guardian’s information.
I have fully discussed the Senior Connects program with a parent
or my guardian and have received their approval to participate in
this program and work with the mentor that I have selected. I am 15
years of age or older. If I am 17 years of age or younger, I have
selected a mentor and have fully discussed the Senior Connects program
with my mentor and my mentor has agreed to help me throughout my participation
with this program.
If I am 17 years of age or younger, I agree that if at any time my
mentor is unable to continue to help me in the Senior Connects program,
I will notify my parents or guardian and discontinue using the Senior
Connects program until I choose another mentor and my parents agree
to my choice of mentor.
I have fully read the Senior Connects method of teaching, understand
it, and agree to abide by the program. I agree to use good common
sense and will take no actions that could compromise my safety or
the safety of any other individual or individuals. I have read and
understand the Terms of Service.
I understand that the Senior Connects method of training is for self
directed and mature individuals that are willing to work independently
and take responsibility for their actions. My parent (or guardian),
mentor (if applicable), and I agree that Senior Connects will not
be held liable for anything directly or indirectly related to me using
their program. I also understand that I may use the Senior Connects
program at no cost to me and on an “as is” basis. My parent
(or guardian), mentor (if applicable), and I have reviewed the Senior
Connects program and have no remaining questions about any of the
policies. I understand that my failure to follow this program terminates
my rights to use this material or indicate that I am using the Senior
Connects program, and will immediately notify Senior Connects if I
have breached any of its provisions.
I agree with all of the provisions specified in the above three paragraphs
and will diligently ensure they are undertaken.
__ Yes __ No
I understand and agree that my contact information and all other information
will be released to independent living facilities when they provide
reasonable requests for information together with your password and
to parents (or guardians) and mentors upon their request and without
them having your password.
__ Yes __ No
Volunteers’ Commitment
I promise that I will do my best to help others.
I will be patient and strive to make sure each senior or individual
that I’m working with is able to learn at a rate of study that
makes them comfortable.
I respect anyone that strives to improve themselves - and hope that
my own quest for knowledge and learning will not diminish when I’m
in my 60’s, 70’s, 80’s and 90’s.
I will never accept any direct or indirect compensation for any assistance
that I provide.
I will be courteous and professional - and promise to act in such
a manner that reflects positively on the independent or assisted living
facility or other complex that has opened their facility.
I will always exercise excellent judgment and keep my contact person
at the facility, my parents (or guardian), and mentor (if applicable)
aware of the progress made during the classes - and promptly discuss
any problems, potential problems, or anything that I’m uncomfortable,
with them. I will follow all guidelines and make certain that I follow
all rules, laws, licensing agreements, use good judgment, and will
always be safe.
If I am 17 years of age or younger, I will select an adult mentor
to work with in accordance with the Senior Connects methodology.
I have thoroughly reviewed this Website, and especially the sections
regarding Senior Connects’ procedures, and will teach senior
citizens using the Senior Connect methodology and follow all of its
policies and procedures.
I agree to abide by the spirit and letter of the Volunteer’s
Commitment.
__ Yes __ No
Please complete the document by keyboarding responses to the above
questions, then save the document and email it to support@seniorconnects.org.
Your privacy is of paramount importance to us - please read the privacy
policy on our Website. You cannot begin using the Senior Connects
program and qualify for awards or recognition programs until you have
received our written approval.
I understand and agree to the above:
Volunteer _____________________________________
Mentor (if required) _____________________________________
Parent or Guardian _____________________________________
Note: typing your name above will constitute your signature on this
document. Exceptional youths that are 13 and 14 years of age may be
approved to participate in the program - please ask your parent, guardian,
or mentor to briefly explain why they recommend it in a short note
accompanying the application that is emailed to us.
Note 2: After you complete this form, cut and paste it to a
Word document or an email and send it to support@seniorconnects.org
Note 3: BY AGREEING TO USE THE SENIOR CONNECTS TRAINING METHODOLOGY OR ANY
INFORMATION ON THIS WEBSITE, YOU, YOUR PARENTS (OR GARDIAN), AND MENTOR
(IF APPLICABLE) UNDERSTAND THAT THIS IS A YOUTH RUN ORGANIZATION AND
AGREE TO PROTECT, DEFEND, AND HOLD SENIOR CONNECTS HARMLESS AGAINST
ANY AND ALL OF YOUR DIRECT AND INDIRECT ACTIONS. USER OF ANY OF THIS
INFORMATION ON THIS SITE, THE SENIOR CONNECTS METHODOLOGY, AND ANY
OTHER DIRECT OR INDIRECT MATERIALS RELATING TO THIS SITE, WILL REIMBURSE
SENIOR CONNECTS CORPORATION FOR ITS DEFENSE OF ANY LITIGATION, ARBITRATION,
OR OTHER FORM OF DISPUTE RESOLUTION DIRECTLY OR INDIRECTLY RELATED
TO YOUR USE OF THIS SITE. WHEW! THAT’S WHAT OUR LAWYERS TOLD
US TO SAY – THAT YOU USE OUR PROGRAM AT YOUR OWN RISK AND ON
AN “AS IS” BASIS. YOU HAVE NO REMEDIES AGAINST US, AND
YOU AGREE THAT ANY USE OF THIS SITE NOT IN COMPLIANCE WITH ALL OF
THE PROVISIONS ON THIS APPLICATION, THE TOS, AND OTHER POLICIES AND
PROCEDURES IS NOT PERMITTABLE AND A BREACH OF THE CONDITIONS BY WHICH
YOU ARE USING THIS SITE. THIS GOES FOR ANYONE THAT SENDS IN THIS FORM
OR NOT – IF YOU’RE NOT AGREEING TO ALL OF THE RULES AND
REGULATIONS ON THIS PAGE, IN THE TOS, AND ELSEWHERE IN THE WEBSITE,
THEN FIND ANOTHER SITE. YOU ALSO AGREE THAT EVERYTHING ON THIS WEBSITE
WILL BE INTERPRETED BY INDIANA LAW – AND PROCEEDINGS OF ANY
SORT WILL TAKE PLACE IN HAMILTON COUNTY, INDIANA.
WHEN YOU’RE A YOUTH-MANAGED CORPORATION OF MIDDLE AND HIGH SCHOOL
YOUTHS THAT ARE JUST TRYING TO MAKE THE WORLD A LITTLE BETTER PLACE
TO LIVE, WE JUST HAVE NO INTEREST IN GETTING INVOLVED IN ANY LITIGATION
OR DISPUTE RESOLUTION OF ANY SORT. LIFE IS JUST TOO SHORT FOR THAT
– SO IF YOU CAN’T BE RESPONSIBLE OR LIVE WITH THIS –
THEN SENIOR CONNECTS IS PROBABLY NOT THE BEST THING FOR YOU TO GET
INVOLVED IN. SORRY, SORRY FOR THE TOUGH WORDS.
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