FIXIT Forward Registration Form Student Name * First Name Last Name Email * Phone * (###) ### #### Gender * Female Male Parent or Guardian's Name If participant is under 18 yrs old, please provide the parent or guardian's name. First Name Last Name Participant's School District If participant is under 18 yrs of age, please provide the participant's school district. Highest Grade Completed * Grade School Middle School High School Some College Bachelors Degree Masters Degree PHD Age * 8-10 years old 11-12 years old 13-15 years old 16-17 years old 18 years old What is your ethnicity? * White Hispanic or Latino Black or African American Native American or American Indian Asian/Pacific Islander Other Have you ever heard of AI technologies such as ChatGPT? * Yes No Have Taken Computer Literacy 101 * Yes No Do you have your own computer device? * Yes No Do you have access to reliable internet service? * Yes No Needs Assessment The purpose of this assessment is to gather information for program offering purposes. All information gathered will be confidential and solely the property of Cedarmore Corporation Inc. for technology planning purposes. This information will be useful in determining course offerings, identifying specific areas of competencies in digital literacy to equipping participants for employment and digital life skills. Survey * I feel confident selecting the appropriate digital formats to meet my needs. Strongly Disagree Disagree Neutral Agree Strongly Agree I feel confident selecting the appropriate digital features to meet my needs. Strongly Disagree Disagree Neutral Agree Strongly Agree I feel confident using digital resources to enhance my learning. Strongly Disagree Disagree Neutral Agree Strongly Agree I feel confident utilizing various types of software applications. Strongly Disagree Disagree Neutral Agree Strongly Agree I feel confident presenting digital information in a useful and understandable format. Strongly Disagree Disagree Neutral Agree Strongly Agree I understand the consequences of using digital information to deceive others. Strongly Disagree Disagree Neutral Agree Strongly Agree I understand how my digital footprint affects how viewers perceive me. Strongly Disagree Disagree Neutral Agree Strongly Agree I feel confident protecting myself against fraud conducted through digital means. Strongly Disagree Disagree Neutral Agree Strongly Agree I feel confident selecting the appropriate digital devices to meet my needs. Strongly Disagree Disagree Neutral Agree Strongly Agree How did you hear about us? * Drove/Walked by location Event Google Ad Walk Up Facebook Ad Newspaper/Magazine Radio Referral Search Engine Social Media Other Terms Of Use * I have read and agree to the Terms of Use Privacy Policy * I have read and agree to the Privacy Policy You have successfully enrolled in theFixIT Forward - Computer Knowledge, Repair, And Laptop Giveback class!provided by the Bishop Frank O. White Digital Literacy Center.An Enrollment Confirmation email will be sent to you shortly with further detailsThank You!,Bishop Frank O. White Digital Learning Center
