Computer Literacy Class Registration Form

Computer Literacy Class Registration Form

CSCL
Name

First NameMiddle NameLast Name
Gender
Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age group
Spoken Language(s)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail
example@example.com
Total Monthly Household Income
Household Size
# of school-age children in the home
Living with Spouse?
Which class schedule works for you? Classes run for 2 hours.
Do you have Internet at home?
Do you need help paying for the Internet?
Do you or someone in your household need assistance with any of the following:
List any other needed service(s)/ assistance
List any accomodation needed during class
Photo Release. I grant permission for COCOMPTS to use videos or photographs of me for educational purposes, promotion of the COCOMPTS CSCL program and/or COCOMPTS Extension programs.
Signature
Should be Empty: