Internet Survey

Please complete the following survey to provide us with information so that we can better serve you. Your information will be kept private and will not be shared with any other organization.

First Name: *Last Name:

Password:

Do you currently have access to the Internet from home? yes no

Who currently uses the Internet in your home! (Please check all that apply)

Adult--Male
Adult--Female
Child--Male
Child--Female

Please select the type of Internet access you use from home:

Briefly explain how you use that Internet in your home:
Enter your answer here

Required