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Independence, Inc. -  Computer Learning Center
June - July
2008 General Classes Signup Sheet  

Name: _____________________________________________________

Street/City: __________________________________________________

Zip: _______________________     Phone: _______________________

Email: _____________________________________________________

Do you have a disability of any sort?    Yes ___    No ___

Are you a Medicaid waiver?                     Yes ___     No ___  

Do you have a Ticket to Work?               Yes ___     No ___

Are you on SSI?  SSDI?                             Yes ___     No ___

Are you on VR (Voc Rehab)?                   Yes ___     No ___     Pending ___

        Counselors name: _________________________

Are you receiving TANF?                          Yes ___     No ___

               Worker's name: _________________________

Are you on the Foster Care
      Independent Living Program?           Yes ___     No ___

Have you used our services before?     Yes ___     No ___

Intro to Computers I:                (4 weeks)                                   Yes, enroll me ___
    Fee $175