2B - Template - Jelly Academy Intake Form: Live Digital Marketing Bootcamp

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone * This field is required.
Phone Number
4
Address* This field is required.
Street Address
Street Address Line 2
City
Province/State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Do you live in a rural or urban area?* This field is required.
Rural area (located outside of towns and cities)
Urban area (within towns, cities or suburbs)
6
Please confirm your employment status:* This field is required.
Not currently employed
Employed, working for a business organization that I do not own
Employed, I own my own business
7
Jelly Academy acknowledges that social and systemic inequities can prevent people from accessing education opportunities, programs and services. In order to ensure that our courses are reaching everyone and meeting the diverse needs of the students, we respectfully ask that you self-identify by selecting the option(s) from the following that apply to you:* This field is required.Disclaimer: Any and all information will remain confidential within Jelly Academy and only necessary information will be shared with our partners and internal stakeholders.
Black (African, Caribbean, European, North American, South and Central American)
Indigenous (Status, Non-Status, Métis, Inuit)
Asian (Asian Caribbean, East Asian, South Asian, Southeast Asian)
Latin/Hispanic (Caribbean, Central American, European, South American, Northern American)
Middle Eastern (North African, Middle Eastern, West Asia)
White or Caucasian
Biracial or Multiracial
I prefer not to answer
Other
8
Which of the following do you most identify as?* This field is required.Jelly Academy collects this information to improve its programming and address the various needs of diverse groups across Canada. Any and all information remains confidential within Jelly Academy and only necessary information will be shared with our partners and stakeholders.
Man
Woman
Non-Binary
I prefer not to answer
Other
9
Which age bracket do you belong to?* This field is required.
17-30
31-40
41-50
50+
10
How would you rate your ability to use everyday digital tools (e.g., Google Docs, Microsoft Office, spreadsheets, file management, video calls)?* This field is required.
Please Select
Please Select
1 - No experience
2 - Beginner
3 - Intermediate
4 - Advanced
5 - Expert
11
How would you rate your ability to learn and troubleshoot new digital tools or platforms independently?* This field is required.
Please Select
Please Select
1 - No experience
2 - Beginner
3 - Intermediate
4 - Advanced
5 - Expert
12
How would you rate your familiarity with digital marketing concepts and channels (e.g., social media, SEO, email, paid ads)?* This field is required.
Please Select
Please Select
1 - No experience
2 - Beginner
3 - Intermediate
4 - Advanced
5 - Expert
13
How would you rate your ability to plan and carry out digital marketing strategies (e.g., campaign planning, content calendars, channel selection, performance tracking)? * This field is required.
Please Select
Please Select
1 - No experience
2 - Beginner
3 - Intermediate
4 - Advanced
5 - Expert
14
Which of the following digital tools or platforms have you used before?* This field is required.Select all that apply
Google Workspace
Microsoft Office
Zoom/Teams
Social Media Platforms (i.e. Instagram, TikTok, Facebook, Pinterest, Snapchat, Reddit)
Social Media Management (i.e. Later, Buffer, Sprout Social)
Content and Design (i.e. Canva, Adobe Photoshop, CapCut)
SEO Tools (i.e. Semrush, Ahrefs)
Website Builders (i.e. Squarespace, Shopify)
Paid Ads (i.e. Google Ads, Meta Ads Manager)
Analytics (i.e. Google Analytics, Search Console)
PR Tools (i.e. Meltwater, Cision, Muck Rack)
Email Marketing Platforms (i.e. Mailchimp, Klaviyo, HubSpot)
CRM/Automation (i.e. Salesforce, HubSpot)
AI tools (i.e. ChatGPT, Claude, Gemini)
Other
15
Why are you interested in taking Jelly Academy's Digital Marketing Bootcamp?* This field is required.
16
Attendance & Learning Resources* This field is required.I will attend 9 classroom sessions over Zoom that are 3 hours in length each. If I cannot attend a session I will inform the course administrator, understanding that I will have access to the session recording and am expected to watch it on my own time. I will sign into the course’s learning management platform in order to access recordings, additional learning resources, quizzes, and sections to upload micro-credentials.
YESNO
17
Requirements for Course Completion: Quizzes & Assignments* This field is required.In order to receive my certificate of completion, I must, at a minimum, complete all quizzes through the learning management system, with a minimum score of 70%. I understand that I can attempt the quizzes as many times as I need in order to score 70%. I must also complete all 9 assignments in order to receive my certificate of completion.
YESNO
18
Requirements for Course Completion: Industry Certifications* This field is required.I understand that this course is built to help me gain 11 industry recognized certifications through Google, Meta, Meltwater, and more. I understand that I do not have to complete all 11 industry certifications in order to receive my certificate of completion. If I do choose to complete a industry certification, I understand it will take, on average, 3 hours to complete each. I understand that by completing 11 industry certifications, I am increasing my opportunity for finding employment in digital marketing.
YESNO
19
Requirements for Course Completion: Deadlines* This field is required.I must complete all quizzes and asssignments within 2 weeks, or 14 days, of the last session of the course, in order to receive my certificate of completion. If I complete the course by the deadline, I will receive an extended 6 months of access to the course on Thinkific.
YESNO
20
Program Acceptance* This field is required.I understand that this program requires me to use digital tools, such as Zoom, Thinkific, Google Skillshop, Hootsuite, Meta, and others, in order to successfully complete the course. Thus, I must have access to a computer, tablet, smartphone or other device in order to participate in, and complete the course.
YESNO
21
By selecting “Yes,” I confirm that all information provided is accurate and that I have read, understand and agree to the course requirements and student commitments.* This field is required.
Yes
No
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