ConnectHome Project Initiative - Intake Application
Through the ConnectHome Initiative, RHA a long with several different internet service providers, non-profits and the private sector are offering broadband access, technical training, digital literacy training and devices for residents.. ConnectHome creates a platform to help ensure that students have access to high-speed internet for things such as studying, research and doing their homework at home, as well as in school.
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(First & Last)
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Address
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Zip Code
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Phone Number
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BIRTHDATE
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E-mail Address
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If you do not currently have an active e-mail address, are you interested in creating one? (Check One)
What is the best way to contact you? (Check One)
Where is your current housing location? (Check One)
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Are you the current Head of Household? (Check One)
How many people currently live in your household? (#)
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List all current household members and their ages , including yourself (EX: John Smith, 12)
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Do you currently have a working computer/laptop in the household? (Check One)
If you DO NOT currently have a working computer/laptop in the household, why? (Check ALL that Apply)
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Do you currently have internet service at home? (Not on your cellular device)
If you currently have internet service, who is your Internet Service Provider? (Check One)
If you currently have internet service, how long has your service been connected?
Are you able to supply us with an updated copy of the most recent bill/statement/etc. from your Internet Service Provider?
If you DO NOT currently have internet service, are you interested in obtaining it?
If you DO NOT currently have internet service, what is the main reason for not having it? (Check ALL that Apply)
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Besides yourself, are there others in the household that would be interested in Digital Literacy Training? (Check One)
What devices do you have experience with? (Check ALL that Apply)
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How would you rate YOUR current computer skills level? (1 - no skill / 5 - expert)
If you participate in Digital Literacy Training, what computer/technology skills are you interested in learning and/or improving (check all that apply)?
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How do you currently use your device or what will you use your device for in your home? (check all that apply)
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Are you currently a participant in the RHA Family Self-Sufficiency Program (FSS)?
Do you currently have an active Rockford Public Library Card?
Are you currently in good standing with RHA? (Current on rent, community service, utilities, etc.)
How did you hear about the ConnectHome Project Initiative?
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Notes:
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