All Programs Form

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Human-I-T Digital Inclusion Help/ Ayuda en inclusión digital de Human-I-T

Preferred language/ Lenguaje de preferencia*

English Español

Which of the following services are you interested in receiving from Human-I-T (select all that apply)?*

Low cost computers Assistance signing up to internet Digital skills training

¿Cuál de los siguientes servicios le interesa recibir de Human-I-T (seleccione todas las que correspondan)?*

Computadoras a bajo costo Asistencia para recibir internet Capacitación en habilidades digitales

Name*

First Name*

Last Name*

Nombre*

Primer nombre*

Apellido*

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Dirección

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Teléfono*

Email*

Correo electrónico

How did you hear about us?*

¿Cómo te enteraste de nosotros?*

Other*

Otro*

Name of School District*

Nombre del distrito escolar*

Name of Friend/Family who recommended us to you*

Please enter first and last name

Nombre del amigo/familiar que nos recomendó*

Por favor, introduzca su nombre y apellido

State You Primarily Live In

Estado en el que vive principalmente

Please confirm how you would like Human-I-T to contact you*

Por favor confirme cómo le gustaría que Human-I-T se contacte con usted: *

Note: Message and data rates may apply / Nota: Se pueden aplicar tarifas de mensajes y datos
Text "Stop" at any time to opt-out of messages / Envía "Stop" en cualquier momento para cancelar la suscripción a estos mensajes

Se pueden aplicar tarifas de mensajes y datos
Envía "Stop" en cualquier momento para cancelar la suscripción a estos mensajes

Check if you would NOT like to receive future news, events and information from human-I-T

Opt-out

Marque si desea recibir futuras noticias, eventos e información de human-I-T

Opt-out

Campaign Source

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Campaign Medium

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Campaign Term

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Campaign Content

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Campaign Name

This hidden field has been added by Attribution to CRM Plugin to store Campaign Name in this Form's submission table

GCLID (Google Click Identifier)

This hidden field has been added by Attribution to CRM Plugin to store GCLID (Google Click Identifier) in this Form's submission table

Demographics

Are you willing to share your demographic information to help us assess and improve the equity and inclusion of our services?*

Yes No

What is the age of the primary user? [select one]

10 or under 11-13 19-29 30-39 40-59 60+ Decline to answer

What is the gender of the primary user? [select one]

Man Woman Gender-variant or non-conforming Decline to answer

What is the ethnicity of the primary user? [select all that apply]

Asian Black/African American Hispanic/Latinx Middle Easter/North African Native Indian/Hawaiian/Pacific Islander White Caucasian 2 or more of the above Decline to answer

How many people live in your household? [select one]

1 2 3 4 5+ Decline to answer

Is someone in your household disabled or receiving SSI benefits?

Yes No Decline to answer

Is someone in your household an active military member or veteran?

Yes No Decline to answer

Is someone in your household receiving unemployment?

Yes No Decline to answer

Demografía

¿Está dispuesto a compartir su información demográfica para ayudarnos a evaluar y mejorar la equidad y la inclusión de nuestros servicios?*

Si No

¿Cuál es la edad del usuario principal? [Seleccione uno]

10 o menos 11-13 19-29 30-39 40-59 60+ No deseo contestar

¿Cuál es el género del usuario principal? [Seleccione uno]

Hombre Mujer No bonario / no conforme Transgénero Prefiero describir mi sexo Un género no listado No deseo contestar

¿Cuál es el origen étnico del usuario principal? [seleccione todas las que correspondan]

Asiático Negro / afroamericano Hispano/Latinx Oriente Medio/África del Norte Nativo indio / hawaiano / isleño del Pacífico Caucásico blanco 2 o más de los anteriores No deseo contestar

¿Cuántas personas viven en su hogar? [Seleccione uno]

1 2 3 4 5+ No deseo contestar

¿Alguien en su hogar está discapacitado o recibe beneficios de SSI?

Si No No deseo contestar

¿Alguien de su hogar es miembro militar activo o veterano?

Si No No deseo contestar

¿Alguien en su hogar recibe beneficios de desempleo?

Si No No deseo contestar