Information Technology & Cybersecurity Student Registration Form
Background Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Age Range
14-19
20-26
27-30
31-40
41-50
51-60
60+
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Educational Background
What is your highest level of education completed?
Have you completed any previous IT or cybersecurity courses?
Do you currently attend another institution? If yes, which one?
Have you earned any IT certifications (e.g., CompTIA A+, Network+, Security+, Cisco, AWS, etc.)?
if so, please upload your certificate or certification below.
File Upload
Browse Files
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Choose a file
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Computer & Technical Skills
How would you rate your computer skills?
Please Select
Beginner
Intermediate
Advanced
What types of computer systems do you use regularly?
Please Select
Windows
MacOS
Linux
Etc.
Have you built or configured a computer before?
Please Select
Yes.
No.
Are you familiar with basic networking concepts (e.g., IP addresses, routers, firewalls)?
Please Select
Yes.
No.
Do you have experience using any programming languages or tools? If so, list them.
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IT or Cybersecurity Experience
Have you ever worked in an IT or cybersecurity-related position?
Please Select
Yes.
No.
What specific areas of cybersecurity interest you most?
Please Select
Network Security
Ethical Hacking
Digital Forensics
Cloud Security
Incident Response
Have you participated in any cybersecurity competitions (e.g., CTFs, CyberPatriot, HackTheBox)?
Please Select
Yes.
No.
Do you have a home lab or use any cybersecurity tools for practice?
Please Select
Yes.
No.
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Learning Goals and Motivation
What are you hoping to gain from these classes?
What are your short-term and long-term career goals in IT or cybersecurity?
Are you planning to pursue any certifications after completing this program?
What type of job or role would you like to pursue after this course?
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Technical Access and Availability
Do you have regular access to a computer with internet connection?
Please Select
Yes.
No.
What operating system do you primarily use?
Please Select
Windows
MacOS
Linux
Etc.
Do you have access to any cybersecurity practice environment (virtual labs, VMs, etc.)?
Please Select
Yes.
No.
What times of day are you generally available for classes or labs?
Please Select
8:00 AM – 10:00 AM
10:00 AM – 12:00 PM
12:00 PM – 2:00 PM
2:00 PM – 4:00 PM
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Additional Information
How did you hear about this program?
Do you require any accommodations or learning support?
Are you interested in mentorship, internships, or job placement assistance?
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Signature
Student Signature
Date
-
Month
-
Day
Year
Date
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