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* 1. Name of Adult who will attend the workshop

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* 2. Email Address 

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* 3. Phone Number (cell preferred)

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* 4. YEAR of birth 

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* 5. Current age range 

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* 6. Gender 

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* 7. Ethnicity/Race

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* 8. Language Spoken Most Often at Home

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* 9. Complete Address of Your Residence

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* 10. What county do you live in (Example: Fulton)

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* 11. Highest Level of Formal Education

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* 12. Annual Household Income (combined total for your household)

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* 13. Do you or any member of your household receive assistance through a government program such as SNAP, TANF, free/reduced lunch, and/or Medicaid?

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* 14. Have you, or anyone who currently lives in your household, ever served in any branch of the United States military?

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* 15. How many Adults are in your household?

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* 16. Are you the parent/guardian/caregiver of any children age 0-17?

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* 17. How many children (ages 0-17) live in your household?

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* 18. How many working computers (desktop, laptop, or tablet) are currently in your home? Please include both those you own and those that may be on loan to you from a school and/or organization.

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* 19. Of the computers in your home, how many do you/your family own?

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* 20. What type of Internet access do you currently have in your home?

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* 21. EMAIL/PHONE/TEXT AGREEMENT -- Inspiredu uses the email address and/or phone number you provide at registration to send reminders of your upcoming workshop and ask you to confirm your attendance. We will also send an email to you after you attend.

NOTE: You do have the option to opt out of email and/or text messages by notifying us of your wish to do so upon your first receipt of either/both.

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* 22. MEDIA RELEASE AGREEMENT -- Inspiredu takes pictures and videos at our workshops for external marketing such as our social media channel and our website or reports that are shared with our funders. The photos, videos, or other materials to be used by Inspiredu do not include personal information such as name, address, phone number, etc.

Please read the following consent:

I am over 18 years of age, and I have the authority to grant this consent for myself and all family members attending this workshop with me today. By clicking the "Yes" button below, you acknowledge that you have read and agree to be bound by Inspiredu's Privacy Policy and the Media & Interview Release, each of which may be updated from time to time and effective on the date posted.

NOTE: You do have the option to opt out of pictures/videos for yourself and your family. If you wish to do so, it is your responsibility to notify an Inspiredu Staff member of your preference to opt-out of pictures/videos on the day of the workshop and sign an "opt-out" statement at that time.

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* 23. Please type the FIRST and LAST NAME of the ADULT who is providing the above consent. By typing your name here, it serves as the electronic signature for the purposes of agreeing to the terms and conditions of the Email/Phone/Text policy, the privacy policy, and the Media Release policy. (Note: Only persons 18 years old or older are authorized to sign this contract.)

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