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info@wecancenter.org
783 Route 28
Harwich Port, MA 02646
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GROW Program Application
GROW Group Member Application Form
Thank you for interest in WE CAN’s GROW Program. This program is limited to up to 8 participants per group. As such, once you complete this application we will set up an interview between you and a GROW facilitator. Following the interview we will notify you as to whether you have been accepted into the program. We use many factors that decide admission to a group and completing this application is not acceptance.
Which Grow Program are applying for? Check one or both:
*
Mondays 9-12 am (11/2/20, 11/16/20, 11/30/20, 12/14/20, 1/4/21, 1/18/21)
Tuesdays 5-8 pm (11/10/20, 11/24/20, 12/8/20, 1/5/21, 1/19/21, 2/2/21)
Note: We will do our best to accommodate your request, but may offer you a spot in a different day & time due to recommendations of facilitators.
Application Deadline for Fall 2020 is October 14, 2020
Note: All info submitted in this form is confidential and will be held to WE CAN's strict confidentiality guidelines.
Part One: Participant Information
Date
*
Date Format: MM slash DD slash YYYY
Name
*
First
Middle
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
This phone is a:
*
Cell
Land Line
Work Phone
Other
If other, please explain:
Email
*
Part Two: Business Information
Name of Business
*
Product or Service
*
Business Address (if different from above)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Website
Is this a business start-up?
*
Yes
No
Date business was (or will be) started
Date Format: MM slash DD slash YYYY
Type of business:
*
Sole proprietor
Partnership
Limited Partnership
LLC
S Corporation
C Corporation
Other
If other:
% of ownership, If Corporation or Partnership
Employees, including owner:
*
Full Time
Full Time - Seasonal
Part Time
Part Time - Seasonal
How many Full Time?
How many Full Time - Seasonal
How many Part Time?
How many Part Time - Seasonal?
In the next 12 months, do you plan to add employees?
*
Yes
No
How many Full Time employees do you plan to add?
How many Part Time employees do you intend to add?
Approximate Annual Revenue:
*
Profitable?
*
Yes
No
Are you willing to share business financials with the group if necessary?
*
Note: This is necessary to be accepted in the group.
Yes
No
Are you able to make a commitment to attend all sessions of the program?
*
Yes
No
Your primary role in the business:
*
What do you hope to gain from the GROW Group?
*
Why did you start/buy/take over this business?
*
What is your short-term goal for the business?
*
What is your long-term vision for the business?
*
What are the two biggest opportunities for your business right now?
*
What are two concerns for your business right now?
*
Are you currently in a program/working with an organization now focused on your business?
*
E for All
CDP
SCORE
Other
None
If other:
What skills/experience do you have to make this business a success? Please check the area(s) where you need assistance:
*
Growing the business
Developing a business plan
Sales and marketing
Budget/determining profitability
Obtaining financing/credit
Being the boss/managing people
Pricing
Other
If other:
Do you have a business plan?
*
Yes
No
If no, do you understand the components of a business plan?
Yes
No
Do you have a working relationship with a bank?
*
Yes
No
Which bank?
How does your support system (family, friends, business, colleagues) support you in running your business?
*
Are there things that get in the way or make it difficult for you to run or manage a business?
*
Did you start (or are you starting) this business due to being unemployed?
Do we have your permission to contact you after the program has concluded to gain your feedback on the program?
*
Yes
No
To assist us as we plan future GROW Groups what is the best time to schedule GROW sessions?
Mornings
Afternoons
Evenings
Part Three: Demographics
WE CAN & the CDP have partnered to offer this program on the Lower/Outer Cape through funding provided by the Massachusetts Growth Capital Corp. The following information is used for statistical & grant purposes for WE CAN & CDP.
Gender:
*
Ethnicity:
*
Non-Hispanic/Latino
Hispanic/Latino
Race/National Origin:
*
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
If other, please specify:
Citizenship:
*
I decline to answer
I am a citizen of the United States
I reside in the United States after being legally admitted for permanent residence
Other:
Handicapped
Veteran
Part Four: Household
WE CAN & the CDP are applying for or has received services paid for with Federal funds to assist its operations. A condition of receiving those funds is that family income information be collected from each participant and is used for statistical reporting. The information you provide will be kept confidential.
Please answer for all household members, including yourself. Based on your most recent tax return, choose the selection below that matches BOTH the the number of persons in your household AND your family’s adjusted gross income range (line 7 on 1040). Please check only ONE box.
One-person household: Below $32,050
One-person household: $32,050 - $51,250
One-person household: $51,250 - $64,100
One-person household: Over $64,100
Two-person household: Below $36,600
Two-person household: $36,600 - $58,600
Two-person household: $58,600 - $73,200
Two-person household: Over $73,200
Three-person household: Below $41,200
Three-person household: $41,200 - $65,900
Three-person household: $65,900 - $82,400
Three-person household: Over $82,400
Four-person household: Below $45,750
Four-person household: $45,750 - $73,200
Four-person household: $73,200 - $91,500
Four-person household: Over $91,500
Five-person household: Below $49,450
Five-person household: $49,450 - $79,100
Five-person household: $79,100 - $98,900
Five-person household: Over $98,900
Six-person household: Below $53,100
Six-person household: $53,100 - $84,950
Six-person household: $84,950 - $106,200
Six-person household: Over $106,200
If none of these categories describe your household, please explain:
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