WE 360 registration 2023

YOUR NAME*

MS. / DR. ETC.FIRST NAMEMIDDLE / INITIALLAST NAMEJR. / III / ESQ / ETC.

YOUR EMAIL*

YOUR MAILING ADDRESS*

STREET ADDRESS OR PO BOX

Street Address Line 2

CITYSTATE

ZIP CODE

YOUR PHONE NUMBER*

AREA CODEPHONE NUMBER

YOUR ENTREPRENEURSHIP STATUS*

Discoverer I: I intend to start a businessDiscoverer II: I currently own a business that produces $30,000 or less in annual revenueProver I: I currently own a business that produces $30,000 to $120,000 in annual revenueGrower: I currently own a business that produces $120,000 to $600,000 in annual revenueScaler: I currently own a business that produces $600,000 or more in annual revenue

YOUR INDUSTRY (FOR WE 360° RECORDS ONLY)*

YOUR RACE (FOR WE 360° RECORDS ONLY)*

AsianBlack / African descent: having origins in Sub-Saharan AfricaHispanic / Latino / Latinx: identify as Hispanic or Latino with ties to Latin America; any raceIndigenous: Alaskan Native, First Nations, Native American, Native Hawaiian, SamoanMiddle Eastern / North African: including the Middle East, North Africa, the Arab WorldWhite / European descent

YOUR AGE (FOR WE 360° RECORDS ONLY)*

YOUR GENDER (FOR WE 360° RECORDS ONLY)*

YOUR PREFERRED PRONOUN (FOR OUR RECORDS ONLY)*

YOUR INCOME (FOR WE 360° RECORDS ONLY)*

WERE YOU REFERRED BY ANOTHER YWCA?

IF YES, WHICH ONE?

COMMENTS (IF ANY)

YOUR DESIRED SESSION*

WE 360° PRE-SURVEY