VPAC FULL STUDENT REGISTRATION 2026

VPAC FULL STUDENT REGISTRATION 2026

PLEASE COMPLETE FORM
First Name

Last NameFirst Name
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthday

MonthDayYear
Date
Social Security Number
000-00-0000
Please upload a copy of your Social Security Card, if you have one.

Cancelof
How long have you lived in Colorado?
Have you registered to vote?
In what state is you Drivers License/State ID issued?
Enter you Drivers License/State ID number?
Enter you Drivers License/State ID issue date?

MonthDayYear
Date
Enter you Drivers License/State ID expiration date?

MonthDayYear
Date
Please upload a copy of your Driver's License/State ID, if you have one.

Cancelof
Country of Citizenship
Alien Registration Number (No Dashes) If you do not have one, put N/A
Resident Card Issue Date.

MonthDayYear
Date
Resident Card Expiration Date.

MonthDayYear
Date
Please upload a copy of your Resident Card, if you have one.

Cancelof
Gender Identity

Other
Marital Status
Ethnicity
Race
Native Language
Are you an out-of-workforce individual?
Are you economically disadvantaged?
Are you active duty military?
Are you a veteran of the military
Are you the spouse or child of a veteran?
Are you registered for Selective Service?
Do you have a Connecting Colorado account?
Do you receive EBT-SNAP?
What is you EBT-SNAP card Number? N/A if you don't have one.
Please upload a copy of your SNAP Card, if you have one.

Cancelof
Do you receive TANF?
Do you receive Medicaid?
What is you Medicaid card Number? N/A if you don't have one.
Please upload a copy of your Medicaid Card, if you have one.

Cancelof
What is the highest level of education you have completed?
Do you have a High School Diploma or GED?
Are you currently employed?
What Curriculums are you interested in?
Are you able to attend all classes for the courses selected?
Why do you want to attend VPAC?
Please list any Student need for any additional support academically, emotionally, mentally, or physically to make camp as successful as possible? THIS IS NOT A DETERMINING FACTOR OF ACCEPTANCE. Put N/A if not needed.
Please list ALL student medical conditions. If student is required to take medication, please request and complete a Medical Consent form. Put N/A if not needed.
Emergency Contact Name and Relation
Emergency Contact Phone Number
Do you understand that completion of this Registration does not secure enrollment? You must qualify and comply.
You are REQUIRED to attend orientation on a Monday from 9:00 AM-12:00 PM at location provided, depending on your course. During Orientation you will meet with a VPAC Team Member, gain an understanding of expectations and commitments, receive your Individualized Education Plan and set goals with our Behavioral Health Team. All students will be encouraged to receive a minimum 5 Behavioral Health resource hours. 2 for Orientation on Friday; 2 for Spiritual Healing Curricula on the first day of class, & 1 for Behavioral Health Engagement. These times are built into curricula and are NOT additional hours from the course. What MONDAY date are you going to attend orientation?
Do you understand that you have full access to the VPAC Student Handbook and Course Catalogue on the website?
Do you understand and agree with this VPAC Student Registration and the Student Agreement?
How are you feeling today?
What support do you need today?
Anything else you'd like us to know?
VPAC Policies

Please carefully read the following FERPA, HIPPA, Background Check, Certification of Information, VPAC Policies
FERPA
The Family Educational Rights and Privacy Act (FERPA) protects the education records of students who are currently enrolled at VPAC. Please see the VPAC Notification of Rights in the catalog for more information. Do you acknowledge that you received the Student Handbook and Course Catalog and fully understand both?
Student Records Disclosure In compliance with federal FERPA regulations, the School may release the following as 'directory information' without student consent: name, program of study, date of attendance and certificate/degree awarded. Students requesting that such information be withheld must complete the appropriate form requesting specifically which directory information should be suppressed. For additional information on the Family Educational Rights and Privacy Act, please see the current VPAC catalog. I agree to the above statement.
HIPPA
Health Insurance Portability and Accountability Act (HIPAA) Defines policies, procedures, and processes that are required for companies that store, process, or handle electronic protected health information (ePHI). At VPAC, we take our responsibilities towards student confidentiality very seriously and have dedicated both resources and time to train our workforce and develop and implement all of the components of our HIPAA Compliance Program. To ensure we are compliant with HIPAA VPAC ensures that we have the required safeguards in place to protect demonstrate HIPAA compliance to our students. VPAC has developed and implemented a comprehensive HIPAA Compliance Program following the HIPAA Privacy and HIPAA Security Rule– focusing on the administrative, physical and technical requirements of the HIPAA Security Rule as it applies to any potential risk VPAC has provided every member of our staff which also includes new hires, annual training. VPAC has a formal established Employee Policy should any HIPAA compliance violations occur. VPAC ensures technological protocols such as: tight access controls, integrity procedures, firewalls, information systems activity monitoring and other audit mechanisms to record access in information systems that use encryption, automatic logoffs, password management procedures, and VPN tunnel. VPAC has conducted a formal risk assessment to identify and document any area of risk associated with the storage, transmission, and processing and has analyzed the use of our administrative, physical, and technical controls to eliminate or manage vulnerabilities that could be exploited by internal or external threats. We are Dedicated to: Ensuring we are compliant with the regulatory requirements of HIPAA/HITECH. Continuing to develop our safeguards to prevent unauthorized access. Adhering to the requirement to encrypt. Maintaining in a secure environment. Monitoring access to both the secure environment and the data. Our HIPAA policies include, but are not limited to, the following key areas: Security Management, PolicyRisk Analysis, PolicyRisk Management Policy, HIPAA Compliance, Workforce Security Policy, Authorization, and Supervision of Staff Procedure, Workforce Access Authorization Procedure, Termination Procedure, Business Associate Policy, Information Access Management, Access to Modification, Security Awareness Training, Security Training, Password Management, Oral Disclosures, Security Incident Procedures, Incident Investigation Procedure, Contingency Plan, Backup Plan, Disaster Recovery Plan, Emergency Mode Operation, Applications and Criticality Analysis, Evaluation of the HIPAA policies and procedures, Business Associates, Physical Safeguards Standards and Policy Workstation Use, Device and Media Controls, Disposal of Media Re-Use, Accountability, Data Backup, and StorageTechnical Safeguards Standards Policy, Access Control, Unique User Identification, Emergency Access Procedure, Automatic Logoff, Encryption Antivirus and Firewalls, VPN Protocol, Additional Safeguards, Employed Audit Controls, Sanctions Policy. We are Confident that Our Comprehensive HIPAA Policies and Procedures: Ensure the confidentiality, integrity, and availability of VPAC students we receive, maintain or transmit identify and protect against reasonably anticipated threats to the security or integrity of the information. Protect against reasonably anticipated, impermissible uses or disclosures. Ensure compliance of our workforce. Do you agree to VPAC HIPPA Compliance statement
Background Check
Background Check Some programs do require a background check for. Some background issues may prevent clinical and/or internship placement, based on employer requirements, which may impact the ability to complete the program. For the purposes of maintaining a safe and productive work environment, some employers may request a background check on employees. If you have an offense, you could be disqualified for employment. I understand to the above statement.
Physical Consent Policy
The undersigned has read and understands the material contained in this form and hereby authorizes the Student named above to participate in physical education and activities including, but not limited to working with equipment, machinery, and physical techniques while enrolled in VPAC. By the very nature, equipment safety and athletic activities can put students in situations in which serious, catastrophic and perhaps fatal injuries may occur. These injuries could include, but are not limited to the following:❒Sprains/strains❒Head injuries❒Unconsciousness❒Disfigurement❒Cuts/abrasions❒Paralysis❒Fractures❒Loss of eyesight❒Death. Students (parents/guardians) must assess the risks involved in such participation and make their choice to participate in spite of those risks. No amount of instruction, precaution or supervision will eliminate all risk of injury. Although the School may suggest or recommend the use of certain equipment, the School does not guarantee that such equipment will be free from defects or protect the Student from injury. By granting permission as a Student to participate in activities, you, (the parent/legal guardian), acknowledge that such risk exists and assume these risks. Participation by Student is voluntary and is not required by the School. The undersigned has read and hereby agrees to hold VPAC, its employees, agents, volunteers and/or sponsors and any other person, firm or corporation charged or chargeable with responsibility or liability, free and harmless from any and all claims, demands, damages, costs, expenses, loss of services, action and causes of action resulting from the use of facilities, equipment and participation by my student in the above named athletic activity, to the fullest extent of the law.Do you agree?
Student Media Release Policy
VPAC requests your permission to reproduce through printed, audio, visual, or electronic means activities in which Student has participated in educational course. Your authorization will enable VPAC to use specially prepared materials to (1) train teachers and/or (2) increase public awareness and promote continuation and improvement of education courses through the use of mass media, displays, brochures, websites, etc. At most, VPAC would use Student’s first name, last initial, and Course. a. I, as a Student (parent or guardian), fully authorize and grant VPAC and its authorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name, image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats, currently developed, (known as “Recordings”), for the purposes stated or related to the above. b.I understand and agree that use of such Recordings will be without any compensation to the Student or the Student's parent or guardian. c.I understand and agree that VPAC and/or its authorized representatives shall have the exclusive right, title, and interest, including copyright, in the Recordings. d.I understand and agree that VPAC and/or its authorized representatives shall have the unlimited right to use the Recordings for any purposes stated or related to the above. e.I hereby release and hold harmless VPAC and/or its authorized representatives from any and all actions, claims, damages, costs, or expenses, including attorney’s fees, brought by the pupil and/or parent or guardian which relate to or arise out of any use of these Recordings as specified above. Granting permission is voluntary. By checking yes, I confirm that I have read and understand the release and I agree to accept its provisions.
By signing below you agree to the above VPAC FERPA, HIPPA, Background Check, Physical Consent, and Media Release policies.
What is the name of the VPAC Team Member who helped you complete this form?
TYPE THE NAME OF THE VPAC TEAM MEMBER WHO LED THIS MONDAY ORIENTATION
Certification of Information
Please read the following: "I hereby certify that, to the best of my knowledge, the information furnished in this application is true and complete without intent of evasion or misrepresentation. I understand the above information is submitted under penalty of perjury and false or misrepresented data is sufficient cause for tuition reclassification or dismissal." "I understand that the answers to the questions in the Residency Information section of this application are required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I confirm that I have reviewed and meet the physical requirements listed for my program of interest. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this application is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. I agree to the above statement.
By signing, Student agrees to all information in this Registration and affirms all provided information is true.
Date

MonthDayYear
Today's Date
Individual Education/Engagement Plan (IEP)
VPAC Case Manager
Behavioral Health Case Manager
Your (Student) Strengths
Your (Student) Areas of Growth
Barriers of Success. Select all that apply.

Other
If Other, list below
PROGRAM STRUCTURE ALIGNMENT

This Individualized Education/Engagement Plan (IEP) follows a five-phase developmental model designed to move the student from interest to workforce readiness through structured engagement, curriculum execution, behavioral health, and certification attainment, as desired. Phase 1: Engagement and Planning IEP Registration Phase 2: Execution Phase 3: Execution Phase 4: Execution Phase 5: Execution Each execution phase includes curriculum completion and measurable skills.
Phase 1: Engagement and Planning IEP Registration

Components: Full Registration, Interview, IEP Development, and Individualized Schedule Objectives:• Confirm student interest and eligibility• Place student into cohort • Full VPAC Registration to assign Student ID • Establish individualized academic support and career goals • Develop student schedule aligned to program structure Outcome: Student has a fully developed individualized pathway plan with clear expectations and supports and formally enrolled in the program pipeline
Deliverables. Select all that apply.
IEP Goals
Curriculum Goals: What are your goals in class?
Career or Skill Goals: What are your goals after you complete the class?
Personal Development Goals: What are your personal goals for you as a person?
VPAC Team Member Signature
VPAC Team Member Printed Name
VPAC Team Member Employee Number
Date

MonthDayYear
Today's Date
Support Services Assigned
Phase 1: Internal Initial Student Tracking
Did student receive 1:1 Behavioral Health Services today?
Did student receive Group Behavioral Health Services today?
VPAC Notes
Behavioral Health Notes
Phase 2: Student Progress Tracking & Check-In

This is to be done after completion of at least one (1) curricula
Certifications Earned
Deliverables
Did Student attend at least 80% of Course(s)?
Instructor Notes:
VPAC Case Worker Notes
Behavioral Health Case Worker Notes
Post-Completion Plan
Next Step-Placement
Registered Apprentice
Registered Apprentice Contact Name
Registered Apprentice Phone Number
Registered Apprentice Website
Registered Apprentice Contact Email
Registered Apprentice Address
Registered Apprentice Start Date

MonthDayYear
Employer
Employer Contact Name
Employer Contact Phone Number
Employer Website
Employer Email
Employer Address
Employer Start Date

MonthDayYear
Date
Next VPAC Curriculum(s)
VPAC Curriculum Start Date

MonthDayYear
Date
DO NOT SIGN THIS UNTIL FIRST CHECK-IN WITH VPAC TEAM MEMBER AFTER EDUCATION/ENGAGEMENT COMPLETION TO CONFIRM EXECUTION PROGRESS. STUDENT SIGNATURE
Date

MonthDayYear
Date
VPAC TEAM MEMBER
Phase 3: Student Progress Tracking & Check-In

This is to be done after completion of at least one (1) curricula
Certifications Earned
Deliverables
Did Student attend at least 80% of Course(s)?
Instructor Notes:
VPAC Case Worker Notes
Behavioral Health Case Worker Notes
Post-Completion Plan
Next Step-Placement
Registered Apprentice
Registered Apprentice Contact Name
Registered Apprentice Phone Number
Registered Apprentice Website
Registered Apprentice Contact Email
Registered Apprentice Address
Registered Apprentice Start Date

MonthDayYear
Employer
Employer Contact Name
Employer Contact Phone Number
Employer Website
Employer Email
Employer Address
Employer Start Date

MonthDayYear
Date
Next VPAC Curriculum(s)
VPAC Curriculum Start Date

MonthDayYear
Date
DO NOT SIGN THIS UNTIL SECOND CHECK-IN WITH VPAC TEAM MEMBER AFTER EDUCATION/ENGAGEMENT COMPLETION TO CONFIRM EXECUTION PROGRESS. STUDENT SIGNATURE
Date

MonthDayYear
Date
VPAC TEAM MEMBER
Phase 3: Student Progress Tracking & Check-In

This is to be done after completion of at least one (1) curricula
Certifications Earned
Deliverables
Did Student attend at least 80% of Course(s)?
Instructor Notes:
VPAC Case Worker Notes
Behavioral Health Case Worker Notes
Post-Completion Plan
Next Step-Placement
Registered Apprentice
Registered Apprentice Contact Name
Registered Apprentice Phone Number
Registered Apprentice Website
Registered Apprentice Contact Email
Registered Apprentice Address
Registered Apprentice Start Date

MonthDayYear
Employer
Employer Contact Name
Employer Contact Phone Number
Employer Website
Employer Email
Employer Address
Employer Start Date

MonthDayYear
Date
Next VPAC Curriculum(s)
VPAC Curriculum Start Date

MonthDayYear
Date
DO NOT SIGN THIS UNTIL THIRD CHECK-IN WITH VPAC TEAM MEMBER AFTER EDUCATION/ENGAGEMENT COMPLETION TO CONFIRM EXECUTION PROGRESS. STUDENT SIGNATURE
Date

MonthDayYear
Date
VPAC TEAM MEMBER
Phase 4: Student Progress Tracking & Check-In

This is to be done after completion of at least one (1) curricula
Certifications Earned
Deliverables
Did Student attend at least 80% of Course(s)?
Instructor Notes:
VPAC Case Worker Notes
Behavioral Health Case Worker Notes
Post-Completion Plan
Next Step-Placement
Registered Apprentice
Registered Apprentice Contact Name
Registered Apprentice Phone Number
Registered Apprentice Website
Registered Apprentice Contact Email
Registered Apprentice Address
Registered Apprentice Start Date

MonthDayYear
Employer
Employer Contact Name
Employer Contact Phone Number
Employer Website
Employer Email
Employer Address
Employer Start Date

MonthDayYear
Date
Next VPAC Curriculum(s)
VPAC Curriculum Start Date

MonthDayYear
Date
DO NOT SIGN THIS UNTIL FOURTH CHECK-IN WITH VPAC TEAM MEMBER AFTER EDUCATION/ENGAGEMENT COMPLETION TO CONFIRM EXECUTION PROGRESS. STUDENT SIGNATURE
Date

MonthDayYear
Date
VPAC TEAM MEMBER
Should be Empty:

VPAC FULL STUDENT REGISTRATION 2026

VPAC Policies

FERPA

HIPPA

Background Check

Physical Consent Policy

Student Media Release Policy

Certification of Information

Individual Education/Engagement Plan (IEP)

PROGRAM STRUCTURE ALIGNMENT

Phase 1: Engagement and Planning IEP Registration

IEP Goals

Phase 1: Internal Initial Student Tracking

Phase 2: Student Progress Tracking & Check-In

Post-Completion Plan

Phase 3: Student Progress Tracking & Check-In

Post-Completion Plan

Phase 3: Student Progress Tracking & Check-In

Post-Completion Plan

Phase 4: Student Progress Tracking & Check-In

Post-Completion Plan