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July 2019 Registration

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Name *

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Last

Email *

Phone Number *

Address *

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City

State

Zip Code

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Date of Birth DD/MM/YYYY *

School Name (High School or College) *

Emergency contact name and phone number *

Describe any extracurricular activities *

What excites you about technology? *

What do you expect to get out of this program? *

What problems do you see in your community and how would you fix them *

I have a good understanding of how to refurbish older computers *

Disagree = 1 Agree = 2 Does not apply = 3

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