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Header Mini Menu
Donate
Volunteer
Main menu
About Us
Our Core: Mission, Vision, and More
Staff
Office Hours
Accountability
Board of Directors
Contact Us
Anonymous Tip Line for Fraud
Careers
Our Impact
Health
Education
Born Learning Trails
Home Visiting Council
Financial Stability
MyFreeTaxes
Basic Needs
SingleCare
Digital Equity & Inclusion
Impact Stories
Meet ALICE
Emergency Food and Shelter Program (EFSP)
COVID Recovery Grants
Get Involved
Give
What Your Dollars Can Do: Impact Calculator
Volunteer
Become a Sponsor
Emerging Leaders
Leadership Circle
Impact Tour
Workplace Campaigns
Campaign Materials
When You Give
ePledge Set-Up Request Form
Kickoff Speaker Request Form
Supply Order Form
Sweepstakes
Media Library
Our Partners
Our Program Partners
Annual Progress Report (APR)
Budget Revisions
Funding Information
Policy & Procedure
United Way Logo Usage and Branding Guidelines
Events
United Way Golf Tournament
Chippewa Valley Spirit Awards
Day of Caring
Dueling Pianos
Lunch & Learn
Stamp Out Hunger
Digital Resource Fair
Newsroom
UWGCV Newsletters
News
Stay Up-to-Date
Main Menu
About Us
Our Core: Mission, Vision, and More
Staff
Office Hours
Accountability
Board of Directors
Contact Us
Anonymous Tip Line for Fraud
Careers
Our Impact
Health
Education
Born Learning Trails
Home Visiting Council
Financial Stability
MyFreeTaxes
Basic Needs
SingleCare
Digital Equity & Inclusion
Impact Stories
Meet ALICE
Emergency Food and Shelter Program (EFSP)
COVID Recovery Grants
Get Involved
Give
What Your Dollars Can Do: Impact Calculator
Volunteer
Become a Sponsor
Emerging Leaders
Leadership Circle
Impact Tour
Workplace Campaigns
Campaign Materials
When You Give
ePledge Set-Up Request Form
Kickoff Speaker Request Form
Supply Order Form
Sweepstakes
Media Library
Our Partners
Our Program Partners
Annual Progress Report (APR)
Budget Revisions
Funding Information
Policy & Procedure
United Way Logo Usage and Branding Guidelines
Events
United Way Golf Tournament
Chippewa Valley Spirit Awards
Day of Caring
Dueling Pianos
Lunch & Learn
Stamp Out Hunger
Digital Resource Fair
Newsroom
UWGCV Newsletters
News
Stay Up-to-Date
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Digital Resource Fair Registration Form
Indicates required field
Basic Information
First Name
Middle Initial
Last Name
Phone Number
Email
Home Address
Address
Address 2
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State/Province
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Alabama
Alaska
American Samoa
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Age
18-21
21-30
31-40
41-50
51-60
Over 60
Origin (check all that apply)
African American/African
American Indian/Alaskan Native
Asian/Pacific Islander
Caucasian/White
Latino/Latina/Hispanic
Middle Eastern
Do not want to share
Digital Resources
Do you have internet at home?
Yes
No
If yes, which internet service provider do you have service with?
Are you aware of the Affordable Connectivity Program?
Yes
No
If yes, where did you learn about this program?
Do you currently own a computer or tablet?
Yes
No
If no, have you previously owned a computer or tablet?
Yes
No
How comfortable are you with technology skills?
Very uncomfortable
Uncomfortable
Somewhat comfortable
Comfortable
Very comfortable
Are you aware of any organizations in Eau Claire County that work on...
Broadband (high-speed internet) affordability issues?
Yes
No
If yes, which organizations or programs?
Broadband (high-speed internet) expansion to underserved/unserved areas?
Yes
No
If yes, which organizations or programs?
Digital skills (technology) training?
Yes
No
If yes, which organizations or programs?
Availability of free or low-cost devices?
Yes
No
If yes, which organizations or programs?
Services
Please check all the services you will use at this event. Check all that apply.
Affordable Connectivity Program (ACP) Enrollment
Purchasing of an Affordable Device ($30)
Internet Service Providers Onsite
Digital Skills Training
Eligibility
Your household is eligible if you are at or below the 200% Federal Poverty Line OR on certain governmental assistance programs (such as SNAP, Medicaid, WIC, Pell Grant, Free/Reduced Lunch, or other qualifying federal programs). If you have any questions about your eligibility please call Amber Scharenbroch at (715) 834-5043.
Total Number of People in Your Household
Number of Children (under age 18) in Your Household
Annual Income
Employment Status
- Select -
Employed (full-time or part-time)
Unemployed
Check any special circumstances that apply.
Refugee Family
Single-parent family
Child with disabilities
Child with school difficulties
Adults with disabilities
None of the above
Other
Enter other…
Check any specific eligibility criteria that applies. If none apply, you are ineligible for the ACP or a $30 device. (check all that apply)
Lifeline benefit
At or below 200 Federal Poverty Line
Low-Income Home Energy Assistance Program (LIHEAP)
Medicaid
Pell Grant (awarded for 2023)
National school lunch programs free/reduced lunch program
Section 8 or other federal public housing assistance
SNAP/Foodshare/Food stamps
Supplemental Security Income (SSI)
Veterans Pension and Survivors Benefit
WIC – Women, Infants, and Children
None of the above
Are you eligible for the ACP or $30 device? (Did you have something checked in the question above?)
Yes
No
Certification
I certify that the information in this form is true and accurate and understand that misrepresentation of any material face may be grounds for ineligibility of a computer and/or future support.
You are ineligible for the ACP or the $30 device. This mean you cannot use the following services at the event:
Affordable Connectivity Program (ACP) Enrollment
Purchasing of an Affordable Device ($30)
Affordable Connectivity Program Information
Which internet service provider do you want to use your ACP credit with?
Charter-Spectrum
AT&T
TDS
Not sure
Other
Enter other…
Affordable Device Information
**You will need to bring cash or check with you to pay for your $30 device at the event.**
Which type of computer do you want to purchase?
Laptop (has built-in camera)
Desktop
Example of a laptop: Example of a desktop:
What will the computer be used for? (check all that apply)
Word Processing (creating, typing, and editing documents)
Email
Job Applications
Internet
Schoolwork
Bookkeeping
Games
Job Skills Training
Other
Enter other…
Liability
I assume all liability associated with the use and disposal of the provided equipment. It is my responsibility to follow all applicable Federal, State, and Local recycling laws. I also release all responsible parties (PCs for People, United Way of the Greater Chippewa Valley, Chippewa Valley Technical College, Augusta School District, and more) from all liability, including any claim for indemnification or contribution. PCs for People shall not be liable under the agreement for any economic or personal damages including loss of profits or revenues, business interruption, and loss of information or data.
Internet Service Provider Information
Which internet service provider onsite do you wish to speak with? (select all that apply)
Charter-Spectrum
TDS
Not sure
Digital Skills (Technology) Training Information
What type of device do you need training on? (select all that apply)
Laptop
iPhone
Android Phone (Blackberry, LG, Motorola, Nexus, Nokia, OnePlus, Pixel, Samsung, Vivo, Xiaomi, etc.).
Smart phone but unsure of type
Other
Enter other…
What digital skills would you like to learn?
Photo Release
I agree on my behalf of myself and my children that we may be photographed, recorded, and videotaped by United Way of the Greater Chippewa Valley, its employees, partners and affiliates or any media without receiving compensation of any kind. I give United Way of the Greater Chippewa Valley, its employees, partners, and affiliates the right to edit, use, and reuse these photos as for future publications.
Electronic Signature (Type Your Full Name)
Confirmation of Legal Signature
- Select -
I understand that selecting this statement constitutes a legal signature confirming that I acknowledge and agree to the above terms and conditions.
Submit
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