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Email (207) 259-5010

Maine General

Please complete this form for each person you refer to the Maine General Tablet Program.

Name of Provider Making Referral*
First Last
Name of Individual Needing Tablet*
First Last
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. If high speed access, they will receive a wireless 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
How much assistance will this person need with Zoom?
- No need for assistance; enrolled in Internet Safety class
- May need initial assistance; enrolled in Internet Safety
- Will need an Individual Learning Plan
Are there any limitations for this person that you would like the tutor 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 State
Please confirm the residential address for this recipient?
Street Address City State
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