Dempsey Dempsey Center Tablet Request Form Please complete this form for each person you refer to the Dempsey Center Tablet Program. Name of Person Making Referral* First Last Name of Individual Needing Tablet* First Last If the individual has their own device, please enter there name here as well.Best phone number to reach this person*If this person has email, please enter it here: Does the person being referred have internet access at home? Yes No Not sure If none or insufficient internet access, they will receive a data tablet. Please describe this person's familiarity with Android tablets/phones? Very experienced; will need little to no assistance Some experience; may need some assistance This is their first tablet or device If they have their own device but need assistance with learning how to use it for telehealth, please select "Other" and enter "Need ILP to learn to use a (name of device).How much assistance will this person need with Zoom? No need for assistance; already knows how to use Zoom May need initial assistance with tablet and Zoom Will need an Individual Learning Plan Are there any limitations for this person that you would like NDEC to be aware of in assisting them with their device? Please provide the name and phone number of a family or friend that can be contacted if we cannot reach the recipient about their tablet? Is there anything else you wish us to know about this referral?If the USPS address is different than the residential address, please enter it here. Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Please confirm the residential address for this recipient? Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Δ