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Fix-It Clinic Sign up Form and Questionnaire

2. First Name

3. Last Name

5. Address1

7. City*

8. State

9. Zip

11. Phone

12. Email *

14. Do you want to particpate in the turkey carving and food waste reduction session?

16. How did you hear about this event?*

18. What item do you need repaired?*

    Please be as specific possible, with brand, model, and year manufactured.

20. What part of your item is broken?*

    Please be specific, including information such as if the problem has been gradual or if there was an event that broke it, and if the problem is constant or occasional.

22. Do you have any guesses about the underlying problem?

24. What have you already attempted to do to fix it, if anything?

26. Please select the category of the item in need of fixing:*

    1. Electronic
    2. Appliance
    3. Miscellaneous
    4. Textile

27. Do you have access to tools (either your own or through borrowing or buying)?

    1. Yes
    2. No

    Your volunteer will discuss with you what you need.

29. Do you have access to a phone or computer with video capability?*

    1. Yes
    2. No

30. File upload

    If possible, please upload a picture of your item as it is, and of the inside of the item if you can take it apart.

32. Terms and Conditions*

    Thank you for participating in the Anoka County Fix-It Clinic (Clinic). These services are provided free of charge. Because this Clinic uses volunteers, the Clinic cannot guarantee the integrity, usability or effectiveness of the repairs undertaken at the Clinic. Neither the Clinic agents nor volunteers accept any liability for any damage or injury to person or property resulting from the use of item(s) repaired. In consideration of being allowed to participate in the Program at no cost to me, I hereby waive, release and forever discharge the Clinic agents and volunteers, and any others action on their behalf, from any and all responsibilities or liability from damages or injuries of any kind to my property, anyone else’s property, or to me or any other person, in my party or otherwise, as a result of my participation in this Clinic.

    1. Yes
    2. No
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field