Digital Literacy Intake Form Question Title * 1. Name Question Title * 2. Email Question Title * 3. Phone number Question Title * 4. Date of birth Question Title * 5. Home address: Address City/Town State/Province ZIP/Postal Code Question Title * 6. What is your race or ethnicity? Asian Black or African American Hispanic or Latino Middle Eastern or North African Multiracial or Multiethnic Native American or Alaska Native Native Hawaiian or other Pacific Islander White Another race or ethnicity, please describe below Self-describe below: Question Title * 7. What is your ethnicity? (Please select all that apply.) Hispanic or Latino Not Hispanic or Latino Question Title * 8. Which of the following options most closely aligns with your gender? Woman Man Non-binary A gender not listed here Prefer not to answer Question Title * 9. What is your household size? Question Title * 10. Do you consider yourself a person with a disability? Yes No Question Title * 11. Family type Single Single with children Married with no children Married with children Widowed Other Question Title * 12. Military status: No military status Spose or military member Veteran Member of the reserve Active Duty National Guard Question Title * 13. Education: High School grad/ GED Non-High School Grad Associates Degree Bachelor's Degree Master's Degree Doctoral Degree Question Title * 14. Employment: Full-Time Part-Time Unemployed Not Applicable Retired Other Question Title * 15. Monthly income (required for the Learn to Earn a Device Program) Question Title * 16. I request Digital Navigator services from GROW South Dakota. I agree to cooperate should I be selected to participate in surveys designed to evaluate GROW SD services. I permit GROW South Dakota or its agent the use of my name and address for GROW South Dakota surveys and information mailings regarding GROW South Dakota products and services. I understand any information disclosed will be held in strict confidence. (GROW South Dakota will not provide your personal information to commercial entities). I authorize GROW South Dakota to furnish relevant information to the assigned person(s).I further understand that the Digital Navigator(s) agrees not to: 1) recommend goods or services from sources in which they have an interest, and 2) accept fees or commissions developing from this digital navigatorrelationship. In consideration of the digital navigators providing assistance, I waive all claims against GROW South Dakota personnel and that of its partners and host organizations, arising from this assistance. Use of Information: The information in this form is to be provided by individuals seeking technical assistance services from GROW South Dakota. The information is collected to help GROW South Dakota to continue the improvement of Digital Navigator programs. The form should be submitted at the site of service to the digital navigator providing the service. I agree I disagree Question Title * 17. Client E-Signature Question Title * 18. Date: Date / Time Date Done