ConnectHome Initiative Intake Application
Through the ConnectHome Initiative, RHA along 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.
Today's Date
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Month
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Day
Year
Date
Name
*
First Name
Last Name
Phone Number
*
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Area Code
Phone Number
Email
example@example.com
Birthday
*
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Month
-
Day
Year
Birthday
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
If you do not currently have an active e-mail address, are you interested in creating one?
*
Yes
No
Maybe
Unsure
Other
What is the best way to contact you?
*
Phone
E-mail
Both
Other
Where is your current housing location?
*
Blackhawk Courts
Brewington Oaks
Buckbee Apartments
Fairgrounds Valley
Jane Addams
Midvale Apartments
North Main Manor
Olesen Plaza
Orton Keyes Court
Park Terrace
Scattered Sites (East or West)
Summit Green Apartments
Housing Choice Voucher (Section 8)
Other
Are you the current Head of Household?
*
Yes
No
Unsure
Other
How many people currently live in your household?
*
Number of Household Members
List all current household members and their ages, including yourself.
*
Back
Next
Do you currently have a working computer/laptop in the household?
*
Yes
No
Unsure
Other
If you DO NOT currently have a working computer or laptop in the household, why? (Check ALL that Apply)
*
Too Expensive
Don't Know How to Use
Prefer to Use Public Computer Labs
Unsure What to Purchase
Not Interested
Not Applicable (N/A)
Other
Do you currently have internet service at home? (Not on your cellular device)
*
Yes
No
Unsure
Other
If you currently have internet service, who is your Internet Service Provider?
*
Ameritech
AT&T
Charter
Comcast
Verizon
Not Applicable (N/A)
Other
If you currently have internet service, how long has your service been connected?
*
Less than 1 year
1-3 years
3-5 years
5-7 years
7 years or longer
Not Applicable (N/A)
Other
Are you able to supply us with an updated copy of the most recent bill/statement/etc. from your Internet Service Provider?
*
Yes
No
Unsure
Not Applicable (N/A)
Other
If you DO NOT currently have internet service, are you interested in obtaining it?
*
Yes
No
Maybe
Unsure
Not Applicable (N/A)
Other
If you DO NOT currently have internet service, what is the main reason for not having it? (Check ALL that Apply)
*
Too Expensive
Unsure How to Set up
Past Overdue Account(s)
Unsure of Local Internet Service Providers
Prefer to Use Public Internet Access
Not Interested
Not Applicable (N/A)
Other
Back
Next
Besides yourself, are there others in the household that would be interested in Digital Literacy Training?
*
Yes
No
Maybe
Unsure
Other
What devices do you have experience with? (Check ALL that Apply)
*
Desktop Computer
Laptop Computer
Tablet
Smartphone
None
Other
How would you rate YOUR current computer skills level? (1-no skill / 5-expert)
*
1 - No Current Computer Skills
2 - Very Basic to No Computer Skills (Can power on a computer but not navigate, use a mouse, etc.)
3 - Some or Moderate Computer Skills (Know some basics, can work a mouse, turn on a computer, search the internet)
4 - Experienced Computer Skills (Can navigate a computer, save files correctly, edit files, run multiple programs, etc.)
5 - Very Experienced to Expert Computer Skills (Very knowledgeable with programs, software, files, formatting, etc.)
Other
If you participate in Digital Literacy Training, what computer or technology skills are you interested in learning and/or improving (check all that apply)?
*
Basic Computer & Internet Navigation
Microsoft Office Suite (Word; Excel; PowerPoint; etc.)
Uploading, Sharing & Saving Documents
E-Mail & Internet + Safety
All of the Above
Not Applicable (N/A)
Other
How do you currently use your device or what will you use your device for in your home? (check all that apply)
*
School (K-12 or higher)
Employment (job search, resume building, etc)
Job-Training and/or Other Training
Health Research and/or Information
Entertainment (Games; Social Networking, etc.)
Not Applicable (N/A)
Other
Are you currently a participant in the RHA Family Self-Sufficiency Program (FSS)?
*
Yes
No
Maybe
Other
Do you currently have an active Rockford Public Library Card?
*
Yes
No
Maybe
Other
Are you currently in good standing with RHA? (Current on rent, community service, utilities, etc.)
*
Yes
No
Unsure
Other
How did you hear about the ConnectHome Project Initiative?
*
Notes:
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