Client Profile Form

First Name
Last Name *
Street Address
Street Address Line 2
ZIP Code
Home Phone
Mobile Phone
How did you hear about us?
What is the primary reason you are seeking support
Would you like to receive our e-newsletter?


If you marked other, please share your race here
Military Status
Furthest level of education completed
Date of Birth
Do you have a disability?


Marital Status
Are you Head of Household?


What is the total yearly income of your household?
How many adults are in your household?
How many children 17 & under are in your household
Electronic Signature *
  • I understand WomenVenture is a nonprofit organization that receives funding from donors, foundations, corporations and contracts to support its services. Participant fees are required for certain services. When a fee is applicable, payment is required before service delivery.
  • I understand it is WomenVenture’s policy not to allow: 1) distribution of non-business phone numbers or addresses of staff, clients and volunteers; 2) lending of money for or provision of transportation or child care; 3) psychological services; 4) sexual harassment of or by clients; 5) violent or disruptive behavior; 6) selling of program lists to mailing services; 7) participation in program while under the influence of illegal drugs or alcohol.
  • I understand WomenVenture will maintain confidentiality of client information and business ideas, and that this information may be included in confidential reporting to funding agencies. I agree to maintain the confidentiality of any business ideas and plans that I may learn from classmates.
  • I understand that services received from WomenVenture serve the purpose of helping clients to achieve or maintain economic self-sufficiency. While WomenVenture may consult on business concerns, clients are responsible for business decisions and the results.
  • I understand that clients may be photographed or videotaped at WomenVenture events, programs and meetings; and that these photos and videos may be used by either WomenVenture or the Small Business Administration for marketing purposes.

I request business counseling service from the Small Business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services. I understand that any information disclosed will be held in strict confidence. SBA will not provide your personal information to commercial entities. I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance.

Your signature certifies that the information is accurate, authorizes WomenVenture and/or its funding agencies to verify the information provided, and indicates that you have read and agree to the items listed above.

Typing your name in the “Electronic Signature” field serves as your signature and indicates acceptance.