Computer Basics Class

Tell us a little about yourself!

ALL REQUIRED FIELDS MUST BE FILLED OUT

We will not share or sell your information.

This information is required in order to participate.

STUDENT First name

STUDENT Last name

Phone

Alternate Phone

Email

Last 4 of SSN

Multi-line address

Country/Region

Address

City

Zip / Postal code

County (Hinds, Rankin, Madison, etc.)

STUDENT Birthday

Month

Day

Year

STUDENT Age

School Name

Current Grade

Anticipated Graduating Year

Gender

Female

Male

Ethnicity

Hispanic or Latino

Non-Hispanic or Latino

Is the STUDENT currently employed?

Yes

No

Highest Grade Completed (STUDENT)

Are you a SNAP/TANF Recipient?

No

Yes

What are you trying to achieve with this class?

Are you a current or former mentee with 100BMOJ?

Yes

No

Are you interested in becoming a 100BMOJ Mentee?:

Yes

No

Does your child have access to a computer and Wi-Fi?

Yes

No

PARENT/Guardian Name(s)

Yes, subscribe me to your email.