DIGITAL INCLUSION COALITION
NDIA INTAKE FORM
The information gathered here will be used to help NDIA better engage, support, and connect coalitions to local and national opportunities and resources. Each coalition should only submit one form; although, coalitions may submit future updates using this form when there are significant changes to coalition roles, responsibilities, and personnel. In most cases, the form should be completed by coalition leadership, a representative, or founding member. General information about coalitions may be shared with NDIA affiliates and partners, and on the NDIA website. Individual names and contact information for coalition representatives collected through the form will not be shared without permission.
Is your coalition submitting a:
New Response
An Update
Basic Information
Coalition Name
*
Formal or Informal
Coalition Abbreviation or Acronym
Optional
Geographic Focus or Area Type (select one)
*
Please Select
Neighborhood
City
County
Region/Metropolitan Statistical Area (MSA)
Tribal Land
State/Territory
National
Name of Geographic Area(s) That Coalition Serves/Focuses On
*
Name of city, county, state, region or country
Approximate Year Formed (YYYY)
*
Website
Optional
Contact Information: Coalition Email Address
General or Official Coalition Email Address (If Applicable)
example@example.com
Contact Information: Primary Coalition Representative
Coalition Representative #1
Name
*
First Name
Last Name
Email address
*
example@example.com
Your Organization Type
Please Select
Library
Workforce Organization
Economic Development
Housing Organizations
K-12 Organization
Higher Education Institutions
Health Organization
Internet Service Provider
Philanthropic and Financial Organization
Non-profit Organization
For Profit Organization
Community Member
Local Government
Regional Government
State Government
Other
Position Within the Coalition
Optional
May we share your information with NDIA affiliates, partners, and on the NDIA website? (This will not add you to any NDIA marketing or other emails lists)
Please Select
Yes
No
Contact Information: Secondary Coalition Representative
Representative #2
Name
*
First Name
Last Name
Email address
*
example@example.com
Your Organization Type
Please Select
Library
Workforce Organization
Economic Development
Housing Organizations
K-12 Organization
Higher Education Institutions
Health Organization
Internet Service Provider
Philanthropic and Financial Organization
Non-profit Organization
For Profit Organization
Community Member
Local Government
Regional Government
State Government
Other
Position Within the Coalition
Optional
May we share your information with NDIA affiliates, partners, and on the NDIA website? (This will not add you to any NDIA marketing or other emails lists)
Please Select
Yes
No
Coalition Composition
Number of Organizations Within the Coalition
*
Types of Organizations Within the Coalition (select all that apply)
*
Libraries
Workforce Organizations
Economic Development
Housing Organizations
K-12 Organizations
Higher Education Institutions
Health Organizations
Internet Service Providers
Philanthropic/Financial Organizations
Non-Profit Organizations
For Profit Organizations
Community Members
Local Government
Regional Government
State Government
Other
Does Any Member Organization Within the Coalition Provide Any of These Digital Inclusion Services (choose all that apply)?
Digital Skills Training
Computer Devices
Broadband Access
Technical Support
Digital Navigation
What Activities Does Your Coalition Perform or Engage In (select all that apply)?
*
Helps Convene and Connect Digital Inclusion Stakeholders
Helps Plan and Coordinate Digital Inclusion Efforts
Helps Gather and Share Resource/Information
Participates in Advocacy Work
Other
Please attach any documents you want to share with regards to your organization (images, mission statement, charter, strategic plan, blogposts, news articles etc.)
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Mission statements, charters, strategic plans, blogposts or news articles
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