BBIPOC/LGBTQ+/Women Founder Visibility Form

  • BBIPOC/LGBTQ+/Women Founder and Entrepreneur Form

  • Health Tech for Medicaid (HT4M) is expanding our database to highlight and support underrepresented BBIPOC*, LGBTQIA+**, women and gender diverse health tech founders.  HT4M envisions that this platform will help give visibility to leaders as well as build and cultivate relationships within the health tech industry of those serving vulnerable populations. We see this database as a potential tool and resource for investors, entrepreneurs, and advocates.  We created this form to source identifying information about entrepreneurs and their organizations for us to include in this database. We appreciate you taking the time to fill out this form.  

    *BBIPOC defined as, black, brown, indigenous and people of color **LGBTQIA+ defined as Lesbian, Gay, Bisexual, Pansexual, Transgender, Genderqueer, Queer, Intersexed, Agender, Asexual, and Ally community

  • Founder Information

  •  -
  • Title

  • Company Information

  • Has your company received funding to date?
  • What type of funding has your company received to date?

  • How much venture funding has your company received to date?
  • Which round of venture funding has your company completed to date?

  • Does your organization work with or serve the Medicaid population directly/indirectly?
  • Are your company’s products or services specifically built to serve a need in any of the following populations?

  • HT4M Visibility Platform Information

    On this last and final page of the form, HT4M asks these questions to source identifying information about the founder to ultimately help give visibility to them as an underrepresented entrepreneur. There is no obligation to fill out any of the questions and HT4M can provide you with more information upon request in the comments section. 
  • Gender Identity of Founder (please select all that apply)

  • Racial/Ethnic Identity of Founder (please select all that apply)

  • If you selected Hispanic/Latinx, which of the following do you most identify with?(please select all that apply)
  • If you selected Asian or Asian American, which of the following do you most identify with?(please select all that apply)
  • Does this founder identify with the LGBTQ+ community?

  • Subcategory Within Health Tech (please select all that apply)

  • Would you be interested in being a part of our listening series spotlight highlighting underrepresented founders?
  • Are you interested in being a part of this database?

  • Thank you for taking the time to fill out this form!

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