First Name

Last Name

Date of birth *

Email *

Section 1

Interest in Technology Pathways

Q1. How interested are you in learning about technology and future careers (AI, cybersecurity, software, etc.)? *

Very Interested

Somewhat Interested

Not Sure Yet

Q2. Which of these areas are you most interested in exploring? (Select up to 2) *

AI & Automation

Cybersecurity Basics

Software Development Fundamentals

Data, Databases & Analytics

Product Design & Systems Thinking

Digital Literacy & Computational Thinking

I’m not sure yet

Q3. Have you ever learned or tried anything related to technology before? *

Yes

No

Q4. If yes, what have you explored or built? *

Section 2

Commitment & Engagement

Q5. Why do you want to be part of the Access to Access program? *

Q6. This is a 12-month program with monthly sessions and activities. How committed are you to completing the full program? *

Fully Committed

Mostly Committed

Not Sure

Q7. How many hours per month can you realistically dedicate to learning and working on projects? *

1–2 hours

3–5 hours

6+ hours

Q8. Are you willing to attend regular sessions, complete assignments, and participate in group activities? *

Yes

No

Q9. How do you usually handle challenges or difficult tasks? *

I stay consistent and work through them

I try but sometimes lose focus

I often stop when things get hard

Section 3

Goals & Future Vision

Q10. What is one thing you would like to learn or accomplish during this program? *

Q11. How likely are you to pursue a career related to technology in the future? *

Very likely

Somewhat likely

Not sure yet

Section 4

Access & Environment

Q12. Which best describes your access to technology learning opportunities today? *

Limited access to programs, mentorship, or resources

Some access, but not consistent

Strong access to programs and support

Q13. Do you currently have reliable access to a computer and internet for learning? *

Yes

No

Q14. Are you the first in your immediate family interested in pursuing a technology-related path? *

Yes

No

Not Sure

Q15. Is there anything about your background, experiences, or environment that has shaped your interest in this opportunity?