Enroll Enrollment Registration FormBy completing this form, you are enrolling in the Maine Digital Inclusion Initiative, a program that provides free computer skills classes and tutoring to Maine residents. Out-of-state residents can access this program for $50/year. If this registration is part of a specific organization, adult education or library program, please enter the name of that organization or program here. We share your contact information and classes attended with the organization you enter below, but we do not share any of your individual confidential information. Contact InformationName* First Last Business Name (if applicable) Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Will accept contact via email Yes Preferred Phone* Preferred Phone TypeMobileLandlinePhone Questions Will accept contact via phone Will accept TXT messages on this Alternate Phone Alternate Phone TypeMobileLandlineBackground InformationTHE FOLLOWING QUESTIONS ARE REQUIRED SOLELY TO ALIGN TO NATIONAL DATA STATISTICS SUCH AS CENSUS DATA IN ORDER FOR US TO CORRELATE OUR PROGRAM IMPACT TO THE NATIONAL AND LOCAL NEED. ALL ANSWERS ARE CONFIDENTIAL AND SECURE AND NEVER WILL WE SHARE YOUR PERSONAL INFORMATION OUTSIDE OF THIS PROGRAM.Education Level*Less than HS/GEDHigh School/GEDAssociateBachelorGraduateEmployment Status*UnemployedEmployed PTEmployed FTRetiredStudentDomestic (stay at home)Gender*MaleFemaleOtherAge Range*17 years or younger18-2021-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485 years and overRace*WhiteBlackHispanicAsianHawaiian/Pacific IslanderAmerican Indian/AlaskanOtherPrefer not to AnswerOther Information Am a Veteran Am Disabled Am a parent/guardian (school age child) Single Parent Household English is my second language (ESL) Yearly Household Income ($)*Less than $10,000$10,000 to $14,999$15,000 to $24,999$25,000 to $34,999$35,000 to $49,999$50,000 to $74,999$75,000 to $99,999$100,000 to $149,999$150,000 to $199,999$200,000 or morePrefer not to answerHousehold Size*Please enter a number from 1 to 100.Are you participating in this class for work?YesNoAre you theEmployerEmployeeAre you a student?YesNoHome Internet Type*DSLCableSatelliteWirelessFiberCommunity Wi-FiOtherDon't KnowNoneHave the following: Desktop computer Laptop computer Tablet Smartphone None I am interested in taking classes because: I want to improve my job skills I‘m here at the request of my employer I want to improve my ability to manage my health/healthcare I want to improve my ability to support my school-aged child I have plans to further my education and need to improve my technology skills I want to manage my social services online I want to improve my ability to find and use online information I want to manage my finances/banking online I want to improve my technology skills for personal reasons I describe my computer skill level as: (select only one) I am new to computers I have a little experience with computers but generally need help to operate them I have some experience with computers and can navigate basic functions but still need help with computers programs/software applications I am experienced on computers and am able to do most things I need/want to but I want to learn more I am an advanced computer user and have no problem operating computers How did you hear about the National Digital Equity Center? Word of mouth Facebook or other social media Google search result Ad on TV Newspaper Ad NDEC Tablet Program NDEC Volunteer Online Tutor Program Presentation/Webinar about NDEC Other (not listed above) Please check as many as apply.Other (please describe) Finally, if you are not a Maine Resident, click here to arrange payment of your $50/year subscription.PhoneThis field is for validation purposes and should be left unchanged.
