Workforce and Continuing Education Interest Form

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Please select your language.

leadsource (for marketing use)

Contact Information

First Name

Last Name

Email Address

Preferred Phone

MobileHomeI do not have a phone.

Home Phone

Mobile Phone

How do you plan on paying for this / these course(s)?

I may need assistance paying for courses and would like to see if I qualify for help (WorkReadyU).My Company wants to pay.I will be paying for the course(s) myself using my own finances, reimbursement plans available to me, and/or a payment plan (Continuing Education including Youth Camps).

Corporate Payment Information

Please click submit and you will be given further instructions.

Self Pay Information

Please click submit and you will be given further instructions.

Date of Birth

Preferred Language

Dallas College Experience

Are you now or have you ever been a student of Dallas College (formerly DCCCD)?

Current or Former StudentConsidering attending (never assigned a Dallas College student ID)

Do you know your student (Dallas College) ID number?

YesNo

Please enter your Student ID Number (numbers only) if you answered yes to the question above.

Example: 0000001. This will help us locate your record. If you do not know your number, please answer no to the previous question.

Address

Street Address

City

5 Digit Zip Code

County

State

Country

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The following responses will help us review your eligibility for career-connected learning programs and resources available to help you on your learning journey.

Program Interest

Please indicate your interest in the following programs.

High School Equivalency (aka GED)

YesNo

English as a Second Language (ESL)

YesNo

Work-based Learning (Earn while you learn. i.e. apprenticeship, internship, work-study, etc.)

YesNo

Fast-Track Career Training & Certifications

YesNo

Select interested Fast-Track Career Training Program

Interested in Continuing Education Allied Health Programs?

YesNo

Select interested Continuing Education Allied Health Program

Pursuing credit courses toward 2-year degree and/or transfer to 4-year university

YesNo

Preferred Dallas College location

Preferred Learning Format

Educational Experience

Highest educational certification received

Are you currently enrolled in one of the following?

Name of school currently attending

What is your anticipated graduation date?

Work Experience

How much work experience do you have?

Are you currently working?

YesNo

Does your current job match your career interest?

Company name of employer

Zip code of work location

If you are a remote employee, please enter "remote"

Your current job title

Your current hourly wage

Military Service Information

Prior or active military service

Yes No

Military Branch

Veteran Status

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As Dallas College expands our role as a place-based, mission-driven anchor institution, we are working to enrich the economic, intellectual, and human capital of the community we serve.

Additional Questions

Please check the box for each type of technology that you have reasonable access to

Tablet	Copier
Laptop	Desktop / PC
Smart Phone	Internet
Hot Spot	I do not have access to any technology.

Select the financial aid applications you have filed for this academic year

NoneFAFSA (Free Application for Federal Student Aid)TAFSA (Texas Application for State Financial Aid)

How did you hear about these program offerings?

Search engine (Google, Yahoo, etc.)Dallas College WebsiteDallas College Social MediaOther Social MediaDallas College Email/NewsletterRecommended by a friendRecommended by a Dallas College employeeLocal Nonprofit Community OrganizationMy employerOther

Specify "Other"

Would you be willing to answer some optional demographic questions?

YesNo

Optional Demographic Information

The following demographic questions below are optional and will help ensure representation and equity in our initiatives and partnerships.

Is English your second language?

YesNo

Race (Press CTRL to select multiple)

Ethnicity

Country of Origin

What is your citizenship status?

What is your primary citizenship?

What is your second country of citizenship?

Sex Listed on Government Issued ID

Preferred Pronouns

Gender Identity

Do you identify with the LGBTQIA+ community?

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Do you have access to a Laptop Computer at Home (Hidden field for prefill on PIRL)

Yes

Do you have reliable access to the internet (HIDDEN FOR PIRL PREFILL)

Yes