Chautauqua Cyber Club, Inc. P. O. Box 251
DeFuniak Springs, FL 32435-0251

New Horizons Application
 

DATES:   Application__________Interview:__________Review__________                                                                  
CCC#_____________________

Title: Mr. Mrs. Miss  Ms. – circle one
Last Name:_______________________  First Name:_____________  Middle___
Address:____________________________________________________________
City:_____________________________  Florida - zip ______________________
Phone #________________________ Cell Phone #________________________
Date of Birth_________________________________

EMERGENCY PHONE NUMBER:    Someone to contact in an emergency
Name:_______________________________ Relationship___________________
Address:____________________________________________________________
Telephone:_____________________________  Cell Phone__________________

INITIAL ASSESSMENT

Are you physically able to access any Walton County Library that has computer/internet?     Yes_____   No______

SECONDARY ASSESSMENT

Interviewers to determine the following functional assessment

Mobility: 
Walking ability____________________ Wheelchair:_________________________
Walker:_____________________ Transportation/Ability:_____________________

Computer contract explained: yes___ no___    Accepted          Rejected

Mail to:  CCC, P. O. Box 251, DeFuniak Springs, FL  32435-0251