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There are three (3) steps in applying to the Computer Lending Library:

First: You must complete and submit this membership application to the program.

Second: You must complete a handrwritten letter of request explaining why you need a computer; deliver or mail it to the Selkrk & District Community Learning Centre. (511 Robinson Ave., Selkirk, MB, R1A 1E5)

Third: Your application and letter of request will be assessed against the program criteria.

*Before you apply, be sure to read the Loan Agreement and our Lending Policies. Failure to follow these instructions may result in your application being rejected. If you have questions regarding the program or the policies, call the Selkirk & District Community Learning Centre (204-482-2111).

*Please remember, receiving a computer through this lending program does not mean you own the computer. Computers are loaned for a specified period of time and recipients are expected to return the computer and its equipment upon completion of the loan term.

Location:

511 Robinson Ave.
Selkirk, Manitoba
R1A 1E5 - map -

Phone:
(204) 482 - 2111

Fax:
(204) 785 - 1316

Email:
june@sdclc.ca

Computer Lending Library Membership Application

The information collected in this application is kept confidential.

1. General Information

Name: Home Ph:

Cell Ph: Work Ph: E-Mail:

Home Address:

City: Prov: Postal Code:

2. Personal Information/Demographics
[This infomation is voluntary, yet helpful to program delivery]

a) Referred by: (or where you heard about the program)

b) Gender: Male Female

c) Marital Status:

Married	Single (no dependents)
Divorced	Single Parent

d) Language Spoken: English French Other:

e) Number in Household (Including self): Adults: Children:

f) Income Source:

Job Own Business Disabiliy Pension Pension
Other

g) What is your current employment status?:

h) Do you have any disabilites requiring specialized computer hardware/software?:

No Yes (specify)

i) Aboriginal Status (if applicable):

Inuit Metis Non-Status
Status - On Reserve Status - Off Reserve

j) Immigration Status (if applicable):

i. How did you arrive in Canada?

Independant Conventional refugee
Family class Provincal nominee

ii. Current living status:

Permanent Resident Canadian citizen Other

iii. Country of origin: Date of arrival:

iv. Have you been English Benchmark assessed? No Yes

If Yes, what level did you attain for each of the following [Level 1-7]

Listening Speaking Reading Writing

v. Are you presently an ESL student? No Yes

If Yes, where? And for how long?

3. Education & Training

a) Education Information
[Highest level attained OR current level attending]

Grade 5	Grade 6	Grade 7	Grade 8
Grade 9	Grade 10	Grade 11	Grade 12
GED	Some College	Some University	Trade Certificate
College Certificate/ Diploma		University Degree
Some Trade Training		Other

b) Are you or any members of your household currently enrolled in a learning program of some sort?
[E.g. grade school, middle school, high school, adult upgrading, vocational training, college, university.]

If so, please fill out the chart below for each person that is attending.

Example:

Person's Name	Name of Program	Name of School
Sam	Grade 3	Happy Thought School
Mary	Adult Grade 12	Lord Selkirk Learning Centre
John	Health Care Aide	Red River College

Person's Name	Name of Program	Name of School

4. Computer Experience & Training

a) Who in your household will be the:

i. primary user?

ii. secondary user?

b) From the selection below, choose the 5 main reasons you have for borrowing a computer. Of these 5 choices, rank them from 1 to 5.
(1 is your main reason; 5 is your least reason)

School (K-Grade 12)	General family needs
Own business	Post secondary studies
Internet access	E-Mail
Employment upgrading/Training	Games
Job search	Online courses/ Distance Education
Computer Awareness	Other

c) Have you ever used a computer before? No Yes

If you answered Yes, which computer programs have you used? [Please include computer games]
Program / Game Name(s) (e.g. Word, Excel, PowerPoint, KidPix, Sims)	How well do you know how to use it? (little bit, good, pretty good, very well)

d) Which computer programs have other members of your household used?
[Please complete this portion of the questionare for each other person who will be using the borrowed computer. If you need more space, please use the bottom additional notes area.]

i Person's Name
Computer Program / Game Name(s)	How well do they know how to use it?

ii Person's Name
Computer Program / Game Name(s)	How well do they know how to use it?