Net Buddy Intake Registration Form First Name:* Last Name:* Nickname: Meaning of Name: Address: Street Address City State / Province / Region Postal / Zip Code Country: Country of Birth: Date of Birth:01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970year Birth Order:First bornMiddle bornLast born Gender:MaleFemaleNonbinaryPrefer not to specify NGO:Nkosi's HavenAlexandra Child Care and Support CentreVelokhaya Life Cycling Academy Mobile: Skype ID: FaceBook ID: Twitter: Linked In: First Career Choice: Second Career Choice: 3 Words that describe NB: 3 Words that do not describe NB: Languages Spoken:AfrikaansChineseEnglishFrenchGermanHindiIsiNdebeleIsiXhosaIsiZuluPortugueseRussianSepediSesothoSetswanaSiSwatiSpanishSwahiliTagalogTshivendaXitsongaOther Other Languages Spoken: Has Baseline Access To:ComputerCell PhoneTabletInternet Baseline Computer Literacy:Used a computerTurned on a computerUsed a mouseClosed a computer windowWritten and sent an emailAttached a document to an emailSearched for information on the InternetSolved a computer malfunctionWritten a blogUsed SkypeUsed video chattingUsed FaceTime chatting Uses Cell Phone for: No cell phone access: Does it matter? Why?: Uses Computer for: No computer access: Does it matter? Why?: Uses Internet for: No internet access: Does it matter? Why?: Uses Tablet for: No tablet access: Does it matter? Why?: Net Buddy gets information for school and homework from:TeacherLibraryGoogleClassmateParent or GuardianNeighbourCommunity MemberOther Other SW/HW, please specify: Net Buddy gets information about higher education from:TeacherLibraryGoogleClassmateParent or GuardianNeighbourCommunity MemberOther Other HE, please specify: Net Buddy gets information about future careers from:TeacherLibraryGoogleClassmateParent or GuardianNeighbourCommunity MemberOther Other FC, please specify: Net Buddy gets information about other teen opportunities from:TeacherLibraryGoogleClassmateParent or GuardianNeighbourCommunity MemberOther Other Ops Y, please specify: School: Education Grade / Level:OneTwoThreeFourFiveSixSevenEightNineTenElevenTwelveVocational Level 1Vocational Level 2Vocational Level 3Vocational Level 4 Education level as of (MM/DD/YYYY): Preferred Study Subjects: Challenging Study Subjects: Post-Matric Plans:ApprenticeshipCollegeInternshipLearnershipUniversityUniversity of TechnologyOther Other PM Y, please specify:SubmitReset Check the box below: