Aetna OhioRISE - Tablet Application

Aetna has partnered with iFoster to provide technology to their members in DJFS custody and enrolled in OhioRISE through the Aetna Connections for Life program.

Please complete all sections of this application. If completing on behalf of a Youth, please share the application with them and provide them with the Terms and Conditions of receiving technology from iFoster.

This contract is made between iFoster Inc and the Legal Guardian and/or Youth Beneficiary, in consideration of the terms and conditions agreed upon by both parties, the mutual promises in this agreement are being acknowledged.

YOUTH APPLICANT INFORMATION

First Name

Last Name

Date of Birth

DJFS Custody

Phone

Alternative Email (i.e. Supportive Adult email)

Alternative Phone (i.e. Supportive Adult phone)

Aetna ID# If unknown, mark UNKNOWN

Connections for Life Eligibilty

CASEWORKER INFORMATION

First Name

Last Name

Phone

As this youth's caseworker, I have confirmed and attest to that this youth is enrolled and receiving benefits through Aetna OhioRISE

Shipping Address: Devices can be shipped directly to where the youth is residing OR to the office address of the caseworker who will give it to the youth. If shipping directly to the youth, please provide the caregiver information below and make sure the youth will be residing there for the next 2 weeks to receive the device. If shipping to the caseworker, please provide their information below and be sure to notify office staff of this delivery. We will send tracking information for the device to the email provided below. It is suggested to send the device directly to the youth to help expedite the process and ensure it gets to the youth, but this is up to the discretion of the case worker.

Your First and Last Name or First and Last Name of Caregiver / Supportive Adult

Email address of recipient for tracking information

Shipping Address (Street Address)

Apartment or Unit Number (n/a if none)

City

State

Postal Code

Will the Youth or Supportive Adult be at this address for the next 2 weeks?

TERMS AND CONDITIONS

The Beneficiary pledges the following:

· Beneficiary will not sell or give away their tablet or laptop (computer).

· Beneficiary acknowledges that no replacement computer will be provided if the original computer is stolen, lost or damaged.

· Beneficiary will read the Computer and Internet Handbook and take care of their computer.

· Beneficiary will call or email tech support (213.459.1128 or tech@ifoster.org ) if they encounter any hardware or software issue with their computer within the warranty period.

iFoster pledges the following terms:

· iFoster will provide Beneficiary with a functioning device for their sole use.

· iFoster will provide a Computer and Internet Handbook with the computer to help the Beneficiary take care of the computer, understand safe surfing and know who to contact in the case of any computer issues.

· iFoster will provide ongoing, free tech support via (213.459.1128) or via email (tech@ifoster.org) as well as access to online 21st century skills training at www.ifoster.org.

iFoster reserves the right to take back the computer should the beneficiary fail to fulfill their commitment as outlined above. If the beneficiary does not fully the above obligations and/or for reasons determined by their social worker or attorney, the beneficiary will be required to return their computer to iFoster or iFoster's local designee.

The State of Ohio has verified that the following apply to the beneficiaries in their care:
- Youth beneficiary does not currently have a safety concern or a court-order against having a computer or other internet-connected device.
- If youth beneficiary lives in a group home (congregate care) that the Agency is responsible for the group home approving of the youth having their own computer and that the proper protocols are in place to ensure the safe storage of the computer when the youth is not on the premise.

For Beneficiaries under the age of 18, the youth's caregiver or legal guardian verifies:
- I approve of the Youth having their own computer. I understand that should the youth beneficiary not use the computer as outlined in this agreement, iFoster or one of its designees can remove the computer from the youth.

By signing below you are agreeing to the terms states above. If completing the form electronically, you may put your initials in the signature box in lieu of your signature.

Youth Signature

Caregiver or Legal Guardian Signature for Youth under 18 years old (put n/a if youth is over age of 18)

Date

Thank you! iFoster will contact you to confirm any applicant information that may be unclear or missing. If everything is accurate, your request will be ordered and shipped within a week and you will receive an email with shipping tracking.

Questions?? - Contact iFoster
General Phone: 213.459.1128
Email tech@ifoster.org

Contact Information