Mozilla DOT Clubs Registration Form

https://docs.google.com/forms/d/1BcArDQ7v9qAA0FH7fbE_1L...

Mozilla DOT Clubs Registration Form This registration form is intended to be used by Club Leaders facilitating Mozilla DOT Clubs. The information collected in this form can only be accessed by DOT and Mozilla staff and will be used to assess the impact of The Mozilla DOT Clubs program. * Required

Personal Information 1. Date of birth * Example: December 15, 2012 2. Region and City *

3. Name *

4. Gender * Mark only one oval. Male Female Prefer not to say Other: 5. Phone number

6. Email address

7. I'm okay with Mozilla and DOT handling my info as explained in this Privacy Notice (https://www.mozilla.org/en-US/privacy/) Mark only one oval. Yes No

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Mozilla DOT Clubs Registration Form

https://docs.google.com/forms/d/1BcArDQ7v9qAA0FH7fbE_1L...

Professional and Educational Experience 8. Highest Level of education completed? * Mark only one oval. Completed Primary School Completed Secondary School Completed High School Completed University/College Completed Vocational/Technical School Left School during Secodary School Left School during High School Some University/College Some Vocational/Technical School Other: 9. Employment status (check all that apply) * Check all that apply. Working full-time Working part-time Working Casually Self Employed Studying Neither working nor studying Other: 10. What level of education are you currently completing (If Applicable) Mark only one oval. Primary Secondary Vocational – Technical College University Private Institution Other: 11. Area of study?

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Mozilla DOT Clubs Registration Form

https://docs.google.com/forms/d/1BcArDQ7v9qAA0FH7fbE_1L...

Work information (If Applicable) Please fill out if you are currently employed. 12. Name of Employer

13. Job Title

14. Employment Sector Mark only one oval. Agriculture/Farmer Industry Handicrafts Service Retail Trades Financial Education Other: 15. Do you have a bank account? Mark only one oval. Yes No 16. Do you have a registered business? Mark only one oval. Yes No Other:

Event Information Information for the event you are currently attending or planning to attend.

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Mozilla DOT Clubs Registration Form

https://docs.google.com/forms/d/1BcArDQ7v9qAA0FH7fbE_1L...

17. Club Leader Name

18. Event Title

19. Date of event Example: December 15, 2012

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