"*" indicates required fields Digital Workshop Center - Mailing Address: 324 Remington St Ste 130 Fort Collins, CO 80524Following regulations set by the Department of Higher Education and the Department of Labor and Employment, we need to collect information about students in specific programs or classes at the Digital Workshop Center. All information collected on this form is secure and encrypted in our database for your protection. We take the collection of your personal information very seriously. If you have any questions about this form, please contact our offices at any time. Digital Workshop Center Student InformationName* First Last Email* Phone*Student Mailing Address*This address will be used to ship any textbooks or materials as needed. Please use a 2 digit code for the State field. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code LinkedIn Profile URL Date of Birth* Social Security Number*Why do you need my social security number? There is a mandatory requirement by the Department of Higher Education and the Department of Labor to collect social security numbers. The goal is for DHE and DLE to be able to better track your career outcomes after you complete training. All of your information is entered on a secure SSL page and encrypted in our database. We take your security very seriously and have all possible measures in place to make sure we protect your information. Program InformationAre you attending a DWC program using any of the following?*Check all that apply. Workforce Center (WIOA Grant) Workforce Center (CVT III Grant) TEC-P Employment First Vocational Rehabilitation (VR) Veterans Education Benefits (VA) DWC Scholarship Payment Plan None I don't know Veteran Payment Options VETTEC VRRAP GI Bill In which County is your workforce, VR, or VA office located?*Are you enrolled in more than 1 Certification program?* Yes No Program 1: Select Your Program Title* Business Administration Data Analytics Digital Marketing Digital Media Production Excel Master Program Frontend Web Development Graphic Design IT Support Network Technician Project Management QuickBooks Bookkeeper UX Design Stand-Alone Classes Blueprint (Digital Literacy) Other This field is hidden when viewing the formProgram 1: Method of Delivery Online Classroom Program 2: Select Your Program Title Business Administration Data Analytics Digital Marketing Digital Media Production Excel Master Program Frontend Web Development Graphic Design IT Support Network Technician Project Management QuickBooks Bookkeeper UX Design Stand-Alone Classes Blueprint (Digital Literacy) Other This field is hidden when viewing the formProgram 2: Method of Delivery Online Classroom Program 3: Select Your Program Title Business Administration Data Analytics Digital Marketing Digital Media Production Excel Master Program Frontend Web Development Graphic Design IT Support Network Technician Project Management QuickBooks Bookkeeper UX Design Stand-Alone Classes Blueprint (Digital Literacy) Other This field is hidden when viewing the formProgram 3: Method of Delivery Online Classroom Program 4: Select Your Program Title Business Administration Data Analytics Digital Marketing Digital Media Production Excel Master Program Frontend Web Development Graphic Design IT Support Network Technician Project Management QuickBooks Bookkeeper UX Design Stand-Alone Classes Blueprint (Digital Literacy) Other This field is hidden when viewing the formProgram 4: Method of Delivery Online Classroom Equipment & Software* I reviewed and agree to have the required equipment/software for this programClick here to review equipment/software specifications page.Pre-Requisites* I have reviewed and completed program prerequisites and/or pre-class assignments Employment & Wage DataCurrent Employment Status* Unemployed / Dislocated Worker Contract / Freelance Part-Time Employment Full-Time Employment Other Reasons for Training* Unemployed / dislocated and looking to re-join the workforce Looking to change careers Looking to update skills at current career Other What specific career goals do you have for your education?*What is your most recent estimated annual income?*Please estimate annual salary only (NOT hourly)Please enter a number greater than or equal to 0.What is your most recent job title?Who is your most recent employer? DemographicsGender* Male Female Non-binary Prefer not to answer What is your racial or ethnic identification?*Mark all that apply White Black / African-American Asian Hispanic, Latino, or Spanish origin American Indian or Alaska Native Native Hawaiian or Pacific Islander Two or more races Other / Unknown (please specify) Racial or Ethnic Identification - OtherPlease specifyHighest Level of Education* High School Associate Degree Bachelor's Degree Graduate of Professional Degree Some College Other Prefer Not to Answer Other Marital Status* Single Married Divorced Widowed Prefer not to answer Other What Industry did you most recently work in?* Accounting/Finance Advertising/Public Relations Aerospace/Aviation Arts/Entertainment/Publishing Automotive Banking/Mortgage Business Development Business Opportunity Clerical/Administrative Construction/Facilities Consumer Goods Customer Service Education/Training Energy/Utilities Engineering Government/Military Green Healthcare Hospitality/Travel Human Resources Installation/Maintenance Insurance Internet Job Search Aids Law Enforcement/Security Legal Management/Executive Manufacturing/Operations Marketing Non-Profit/Volunteer Pharmaceutical/Biotech Professional Services QA/Quality Control Real Estate Restaurant/Food Service Retail Sales Science/Research Skilled Labor Technology Telecommunications Transportation/Logistics Other If Other, please enter the Industry you most recently worked in:How did you hear about us?* Online search/Google Employer Local Organization Personal recommendation Social Media Other Employment and Wage Data*I agree to provide up-to-date employment and wage data to DWC within 6 months of graduation as required by State law. I agree Consent to Enrollment Agreement*By submitting this form, you agree to the Enrollment Agreement in our Terms and Conditions, our Privacy Policy, and to receive email updates from DWC. I agree This field is hidden when viewing the formI agree to the program cost as outlined in estimate number providedStudent Signature*Please sign in the box below using your mouse or mobile device.Your NameYour NameYour NameYour NameDate Signed* Date
