(Please PRINT legibly - except for the signature, of course)
Organization or Affiliation:_________________________________
User Signature (required!)__________________________________
Signature of parent/guardian for minors______________________
In order to be able to verify your identity over the phone or by email (in case of password problems, etc.), we need a verification code. This will be in the form of a question that you want us to ask you, and the answer. For example, you might have the question be: "What is the name of my dog?", and supply the answer. Then if we need to verify your identity, we will ask you the question, and you supply us the answer. If we don't have this verification information, then we will need to send new passwords or other information to you in the mail.
If you do not want your real name (as listed above) to appear with your e-mail or contributions to public forums, check here: _____________ (If you make this selection, only your user-id will appear in the header information.)
For a free user-ID, fill out the section above. SCN will automatically assign you a unique identifier (for example, bb001), which you use when you login to the SCN system and to receive electronic messages (e-mail).
If you prefer, we can assign you a customized user identification (user-id). For this, we request a voluntary one-time donation of $25.00. To get your custom ID, fill out the section below. You must include three choices, in order of your preference (some user IDs may be already in use). They will be lower case letters and digits only, up to eight (8) characters each.
In addition, the SCN project always needs additional funds. Please consider making a donation to cover costs, especially much-needed hardware upgrades!
Donations will be published unless you check here _______ to make this donation anonymous.
_______ $25.00 (custom user-id)
_______ $25.00 (Basic)
_______ $50.00 (Family)
_______ $100.00 (Patron)
_______ $500.00 (Corporate)
_______ (other, please specify amount)
_______ Total amount enclosed (make checks payable to SCNA)
Thank you for taking the time to become a registered user of the Seattle Community Network. We will send you your identification, password and login instructions by US Mail. Send completed, SIGNED registration form and optional donation check (made out to SCNA) to:
For questions, send e-mail to: SCN