First Name*
 
 
Last Name*
 
 
 
Street Address*
 
 
 
 
City*
 
 
State*
 
 
 
Zip Code*
 
 
County
 
 
 
Email*
 
 
Phone Number*
 
 
 
Race
 
 
Ethnicity
 
 
 
Gender
 
 
Birthday
 
 
 
Education
 
 
Military Status
 
 
 
Do you identify as LGBTQ?
 
 
Do you have a disability?
 
 
 
Marital Status
 
 
 
 
The following income and household information is used to award scholarships for our services, we strongly encourage completion to assist in determining scholarship eligibility.
Annual Household Income
 
 
 
 
Annual Personal Income
 
 
 
 
Adults in Household
 
 
 
 
Children in Household
 
 
 
 
Are you head of household for tax purposes?
 
 
 
 
How did you hear about WomenVenture?
 
 
 
 
Business Phase
 
 
 
 
What is the primary reason you are seeking support?
 
 
 
 
Would you like to receive our e-newsletter?
 
Yes
No
 
 
 
I understand WomenVenture (“WV”) does not allow: distribution of contact information of staff, clients or volunteers; provision of fees for transportation, childcare or psychological services; assault or harassment of or by clients; disruptive behavior; participation in programs while under the influence of illegal drugs or alcohol.
I understand WV will maintain confidentiality of client information and business ideas, and that this information may be included in confidential reporting to funding agencies. I agree to maintain the confidentiality of any business ideas and plans learned from classmates.
I understand that while WV may consult on business concerns, clients are responsible for business decisions and the results. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur in making business decisions. I release, waive and forever discharge any and all claims against WomenVenture for any injury to me resulting from my business decisions.
I understand that clients may be photographed or videotaped at WV events, programs and meetings; and that these photos and videos may be used by WV or the Small Business Administration (“SBA”) for marketing purposes. WV will honor client requests to not have one’s image used.
I request business counseling service from the SBA or an SBA Resource Partner. I agree to cooperate in surveys designed to evaluate SBA or WV services. I permit SBA and WV the use of my name and address for surveys and information mailings regarding their products and services. I understand any information disclosed will be held in strict confidence. SBA and WV will not provide your personal information to commercial entities. I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance.
Your signature certifies that the information on this form is accurate and indicates understanding and agreement to the statements listed above.
E-Signature*
 
 
Today's Date*