WomenInTech (WiT) Beneficiary Form

Please fill all sections

Registration Date:

1. BENEFICIARY INFORMATION

Full Name

Phone Number

Email Address (optional)

Age

Home location (City Suburb)

Country

Martial Status
MarriedSeparatedWidowedSingle

Have Children?
YesNo

At what age did you get married or have your first child? (Estimate if not sure)

If you select NO, write "0" in the number of children section

Number of Children

2. EDUCATION INFORMATION

Highest Level of Education

Never Went to SchoolLower PrimaryUpper PrimaryUpper Primary CertificationLower Secondary (O'level)Post-Lower Secondary CertificationUpper Secondary (A'Level)Post-Upper Secondary CertificationDiplomaUndergraduate DegreePostgraduate Degree

Education Details (Optional)

3. LIVELIHOOD

What do you as an individual do for a living to support your family?

How was your livelihood affected by COVID-19?

4. DIGITAL LITERACY

Do you have a smartphone/computer? or have you used a smartphone/computer before?

Select from below options

NoYes, I have used a smartphone beforeI have a smartphone

What do you use a smartphone/computer for?(optional)

If you don't use or has never used it before, what do you think its used for?

Have you got a social media (Facebook, WhatsApp, Twitter) account?
NoYes

If you use social media, tell us those that you use (optional)

Have you ever shopped online using the internet or an application? Using which service?(optional)

If we were to teach you something about digital technologies, what would you be interested
in learning about?

5. WiT PROGRAM ENROLLMENT

Would you be interested in knowing how technology would improve your business and quality of life?
YesNo
We shall enroll you and train you on how to use digital technologies safely to improve your entrepreneurial competitiveness. Do you consent to document your participation in the WiT project?
YesNoMaybe
Anything else you want to share about your livelihood and family wellbeing?

Name/I.D no. of WiT Team Member collecting the Information:

6. PRIVACY ACT STATEMENT

The collection of this information is relevant and necessary to document and account for WiT activities. Submission of the information requested is voluntary; however, your failure to supply requested information may impede or preclude the beneficiary's enrollment process. The beneficiary must provide the data requested during registration, for example, name, address, and email address. We also record the date and time of registration and the IP address. As part of the registration process, we obtain your consent for the use of the data.

The information collected is maintained in the Privacy Systems of Records. The information collected may be disclosed in accordance with the routine uses referenced in those notices or as otherwise permitted by law. In accordance with those routine uses, Cyber Aware Africa may disclose information collected here to project funding partners as proof of project implementation.

7. DIGITAL SIGNATURE

Read the following statement below, and confirm your agreement by typing your full name below in the box provided:

By digitally signing this document, I affirm that the information I provided is true and accurate to the best of my knowledge. I understand that providing false information could make me subject to discontinuation from the WiT Program.

I accept the Privacy terms of this website

Digital Signature

Type beneficiary's Full Names here

All fields are mandatory