Become a Digital Connector

Not a Digital Connector but thinking about joining the movement?

Fill in the form below to apply for a Digital Connectors program near you (all fields are required).

You can also download the application as a pdf. below. If you are 14-17 years of age you will need your parents permission.

First Name: *

Last Name: *

Email Address: *

Program Name: *

Your Age Range: *

How did you find us?: *

City, State, Zip Code: *

Phone Number (10 numbers in a row, no parentheses or spaces): *

Date of Birth: *

1 Parent/Guardian Name: *

2 Parent/Guardian Name: *

1 Parent/Guardian Phone Number (10 numbers in a row, no parentheses or spaces): *

2 Parent/Guardian Phone Number (10 numbers in a row, no parentheses or spaces): *

1 Parent/Guardian E-mail Address:

2 Parent/Guardian E-mail Address:

Name of High School: *

Grade: *

Expected Year of Graduation: *

Please list your previous work and/or volunteer experience. Start with the most recent: *

Include Employer Name, Position, Dates Employed, Supervisor/Address/Phone Number

Please rate your ability to use computers: *

Have you ever TAKEN a technology course or training before?: *

If Yes to previous question, please list Course Name and School Name:

Have you ever TAUGHT a technology course or training before?: *

If Yes to previous question, please list Course Name and School Name (2):

Do you have a computer at home?: *

Do you have Internet access at home?: *

How often do you use a computer?: *

How often do you surf the web?: *

Skills with Internet (Internet Explorer, Firefox, etc.): *

Skills with E-mail (Outlook and Web): *

Skills with Instant Messenger (AOL, Yahoo, etc.): *

Skills with Microsoft Office (Word, Excel, Access, etc.): *

Skills with Web Design (HTML, Dreamweaver, etc.): *

Skills with Digital Media (Music, Photography, Video): *

Skills with Graphics (PhotoShop, Illustrator, etc.): *

Skills with PDAs/Handhelds: *

Skills Wiring and Cabling for Networks: *

Skills with Software Installation: *

Skills with PC Troubleshooting and Maintenance: *

Skills with Windows XP/Vista: *

Skills with Mac O/S: *

Skills with Network Administration: *

Skills with Blogs, Discussion Groups, Podcasting: *

Please describe a situation where you have been a teacher to someone: *

As a leader, what are your strengths and challenges?: *

What are your future goals?: *

Attachment	Size
DC Program Application v. 5.pdf	195.83 KB

Attachment:

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Become a Digital Connector

Not a Digital Connector but thinking about joining the movement?

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