Southwest Initiative Foundation

First Name

Last Name

Contact Information

Address (Include Apartment Number)

City

State

Zip Code

Email

Home Phone

Cell Phone

I would like to receive text messages with updates, event reminders, and important news.

Message and data rates may apply.

YesNo

Emergency Contact

In the case of an emergency, who should we contact? (providing this is optional)

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

DEMOGRAPHIC & HOUSEHOLD INFORMATION

The following questions are asked so that we can provide the best possible services and for our internal purposes only. Our mission covers services to traditionally marginalized groups so we ask these questions to ensure we are reaching certain populations. However please note your eligibility to take part in the program is NOT effected by your responses to ANY of these questions.

Demographics 1

Gender you identify as

Date of Birth (MM/DD/YYYY)

Please describe your national or ethnic background: (If you belong to more than one group, pick the one you MOST identify as)

Ethnicity

Demographics 2

Do you identify yourself as a member of any of the following groups?

Our mission includes helping people from these groups.

A Person With a Disability

A Person Who is a Veteran

A Person With a Past Bankruptcy

A Person Who is a Refugee

A Person With a Crime Conviction

A Domestic Violence Survivor

A Person Who Was Formerly Incarcerated

Were You Born Outside of The U.S.?

Country of Origin

Number of Years in The United States

Child Birthdates


Child Birthdate 1 (MM/DD/YYYY) Child Birthdate 2 (MM/DD/YYYY) Child Birthdate 3 (MM/DD/YYYY) Child Birthdate 4 (MM/DD/YYYY) Child Birthdate 5 (MM/DD/YYYY) Child Birthdate 6 (MM/DD/YYYY) Child Birthdate 7 (MM/DD/YYYY) Child Birthdate 8 (MM/DD/YYYY)

SELF - Income Last Month

Your Salary from job(s)

Your Self Employment income

Your Unemployment Benefits

Your Child Support/Alimony

Your Social Security/Retirement

Your Disability / Worker’s Comp

Your Public Assistance

Your Other Income

OTHER ADULT(S) IN HOUSEHOLD - Income Last Month

Their Salary from Job(s)

Their Self Employment Income

Their Unemployment Benefits

Their Child Support/Alimony

Their Social Security/Retirement

Their Disability / Worker’s Comp

Their Public Assistance

Their Other Income

Cover Monthly Expense

To what extent does your current monthly household income enable you to cover your monthly expenses?

SELF - Income Last Year

Your Salary from job(s)

Your Self Employment income

Your Unemployment Benefits

Your Child Support/Alimony

Your Social Security/Retirement

Your Disability / Worker’s Comp

Your Public Assistance

Your Other Income

OTHER ADULT(S) IN HOUSEHOLD - Income Last Year

Salary from job(s)

Self Employment income

Unemployment Benefits

Child Support/Alimony

Social Security/Retirement

Disability/Worker’s Comp

Public Assistance

Other Income

Did your personal or household income change significantly since last year, or do you expect it to change soon? If so, please explain.

Business Information

Are you currently making any sales?

Does your business have a name?

Business Name

Business Website

Is the contact information of your business the same as your personal contact information?

Business Phone

Business Email

Is the address of your business the same as your home address?

Business Street Address

City

State

Zip Code

Business Details

How long has your business been making sales?

What was the date of your first sale? (an approximate is ok)

Have you registered your business?

Do you have a separate bank account for your business?

Where is your business located?

Do you work Full-Time or Part-Time on your business?

Do you pay anyone else to work for your business?

Business Employees

Number full-time employees

Number part-time employees

Number contracted/temp employees

Business Financials

What were your total sales/gross revenue Last Month?

What were your total sales/gross revenue Last Year?

Are you able to pay yourself a salary OR pay any personal expenses from the business?

Self Salary

If YES, how much did the business pay you Last Month?

If YES, how much did the business pay you Last Year?

Have you ever applied for a loan for your business?

Have you ever received a loan for your business?

Where was the loan from?

Describe Your Business/Business Idea

Briefly describe the business/idea you will be working on in class. Please be sure to tell us what you are selling and whether or not you are already in business.

Tell us why you want to start or expand this business.

Do you have any work and/or educational experience related to your business idea?

Please describe any work, life, education or family experience related to the business you are describing here.

Please describe any skills or talents that will help you with this business.

What do you want to learn from the Community Business Academy?

What do you think are some of the challenges you will face starting or growing your business?

Briefly tell us why you will be a great candidate for the Community Business Academy.

SERVICE AGREEMENT

BY SUBMITTED YOUR APPLICATION YOU ARE AGREEING TO THE FOLLOWING CONDITIONS

YOU CERTIFY THAT IF ACCEPTED INTO THE COMMUNITY BUSINESS ACADEMY:

You will be able to attend every class for the time slot chosen
You will arrive on time for each class
You are able to attend for the entire length of the class
You will complete and submit all take-home assignments
You agree to participate in follow-up surveys conducted by Southwest Initiative Foundation for the next 5 years

All Services and Documents are provided by Southwest Initiative Foundation on an “as is” and “as available” basis without any express or implied warranties, representations, or guarantees of any kind, including, but not limited to, any of merchantability, fitness for a particular purpose, title or non-infringement, or arising from course of dealing, trade, or performance.

LIMITATION OF LIABILITY
Neither Southwest Initiative Foundation nor its officers, directors, agents and employees, successors, assigns, agents and licensees (the “Southwest Initiative Foundation Parties”) shall be liable for any special, indirect, consequential, incidental, punitive or exemplary damages, even in the event of the foreseeability or advisement of such damages to or the negligence of the Southwest Initiative Foundation Parties, or in the event of a failure of essential purpose and regardless of the theory of liability. In no event shall Southwest Initiative Foundation liability to Client, even for direct damages, exceed $100. Client must bring any claim against the Southwest Initiative Foundation Parties within one (1) year of the event giving rise to Client’s cause of action, and failure to do so nullifies the claim.

RELEASE OF INFORMATION
I give Southwest Initiative Foundation permission to release my personal and business information to its funding sources. I also give Southwest Initiative Foundation permission to use my personal and business information for program management and research purposes. I understand that the use of this information by Southwest Initiative Foundation will be limited to funding sources and research, unless otherwise required by law or to protect Southwest Initiative Foundation’s business interests. I agree to release any claims I may have against Southwest Initiative Foundation and its employees arising out of or related to the release of personal and business information as provided in this authorization.

All of the application information is complete and accurate to the best of my knowledge. I understand that submitting this application does not guarantee acceptance into The Community Business Academy.

PHOTO PERMISSION
Submission of this application constitutes an agreement for Southwest Initiative Foundation, or anyone authorized by Southwest Initiative Foundation, to record and use, as Southwest Initiative Foundation may desire in its sole and absolute discretion, all recordings and reproductions or depictions of such individual or attendees name, likeness, voice, persona, words, actions, and/or biography, which Southwest Initiative Foundation or anyone authorized by Southwest Initiative Foundation may make, including without limitation, the right to for Southwest Initiative Foundation, or anyone authorized by Southwest Initiative Foundation, to use such recordings, reproductions, or depictions in or in connection with any legitimate purposes, including for advertising, publicity, trade and editorial purposes, at any time in the future in all media now known or hereafter developed, throughout the world.

I acknowledge that I will not receive any compensation of any kind for the use of my image, voice and/or biography as set forth above and hereby release Southwest Initiative Foundation and/or its agents from any and all claims which arise out of or are in any way connected with such use.

I have the right to contract in my own name. I have read this agreement and I fully understand it. This permission shall be binding on me and my heirs, legal representatives and assigns