Entrepreneur Introduction Form.
Every quarter, we invite extraordinary entrepreneurs to join StartUp Health Moonshot Academy and become lifetime members of our global army of Health Transformers.
Prior to joining, you will meet with our Ventures team so we can get to know you and the health moonshot you are working to achieve. As a first step, you'll complete this Entrepreneur Introduction Form - answering a few simple questions and selecting the phrases that best describe you as an entrepreneur.
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Full Name
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First Name
Last Name
Company Name
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Title
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Email
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example@example.com
LinkedIn Profile
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Please include a direct link
Company Website
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Please include a direct link
Company's Primary Location
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City, St and/or Country
Founder Roles & Bios
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Your Mindset
Your Commitment:
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Your Relationships:
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Your Rhythm:
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Your Confidence:
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Your Self-Awareness:
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Your Habits:
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Your Future:
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Your Energy:
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Your Company
Your Company's Story:
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Your Company's Team:
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Your Company's Brand:
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Your Company's Traction:
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Your Company's Business Model:
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Your Company's Technology:
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Your Company's Partnerships:
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Your Company's Capital:
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Number of Full-Time Team Members
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Working solely, full-time on the company
Your Product Stage
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Concept
Prototype
Beta
Market
Total Capital Raised to Date (type and amount)
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(e.g. $200K F&F or $5M Series A, etc.)
Months of Cash Runway
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Presentation Link
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Please provide a link (Dropbox, Google Drive, etc.) to your most recent presentation deck.
Why do you want to join StartUp Health? Select all that apply.
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Receive ongoing coaching via quarterly workshops, weekly feedback sessions and 1:1 support during critical moments
Join a trusted peer network with other "Health Transformers" who want to achieve "Health Moonshots" that make a global impact
Access a curated global network of investors, customers and partners with the right mindset
Get promotion and exposure via a media platform and events that reach more than 200,000 influencers
Become a powerful magnet to continually attract the right team, customers, investors, and partners
All of the above
Which Health Moonshot are you working to achieve? Select all that apply.
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Access to Care
Cost to Zero
Cure Disease
End Cancer
Women's Health
Children's Health
Nutrition & Fitness
Brain Health
Mental Health & Happiness
Longevity
End Addiction
Would you like to be presented to the Chiesi Pharmaceuticals team as part of our search with them for companies addressing rare diseases?
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Yes, please!
No, thanks!
How did you hear about StartUp Health?
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Website
Newsletter
Social Media
Industry Event
Met StartUp Health Team Member
Referral
Attended StartUp Health Festival
StartUp Health Team Member met or referred by:
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Steven Krein
Unity Stoakes
Katya Hancock
Bari Krein
Polina Hanin
Lauren Doolan
Logan Plaster
Referred By:
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Your Phone Number
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-
Area Code
Phone Number
Your Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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