Digital Literacy Assistance Registration Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Date of Birth

Date

Preferred Contact Method

Other

What is your current level of digital literacy?

Other

Please describe your main goals or areas where you need digital assistance.

Preferred Learning Format

What days/times are you generally available for assistance?

Which language(s) do you prefer for instruction?

Other

Do you have any accessibility needs or special requirements?

How did you hear about this digital literacy assistance program?