ConnectHome 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) *
Required
Are you the current Head of Household? (Check One) *
How many people currently live in your household? (#) *
Your answer
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) *
Required
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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