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Client Intake FormAs part of the Women’s Business Development Council’s (WBDC) reporting requirements to funders, we ask that you complete this form annually and/or whenever your information changes. Your cooperation in filling out the form is greatly appreciated. All of your information is kept confidential and reported on anonymously, unless you provide prior approval. This form can be returned to childcarebusiness@. Section 1: Personal InformationDateHow did you learn about WBDC?First NameMILastBirth Date (mm/dd/yy)Home AddressCityStateZipPrimary Email? Check to receive newsletterSecondary Email? Check to receive newsletterPrimary Phone #? Cell ? Home ? WorkSecondary Phone #? Cell ? Home ? WorkPreferred Language? English ? SpanishBiological Sex? Female ? MaleMarital Status? Single ? Partnered? Married ? Separated ? Divorced ? WidowedAre you of Hispanic, Latino, or of Spanish Origin?? Yes ? No Race (select all that apply)? Asian? Black or African American ? Native American or Alaska Native? Native Hawaiian or Other Pacific Islander ? White or Caucasian ? Other - specify: Do you consider yourself to be a person with a disability?? Yes ? NoMilitary Status? No Military, Reserve, or National Guard Service ? Veteran ? Service Disabled Veteran ? Member of the Reserve ? Member of the National Guard ? Active Duty ? Military SpouseHighest Level of Education? Some High School ? High School/GED ? Some College? Vocational Training? Associate Degree? Bachelor’s Degree ? Master’s Degree ? DoctorateHead of Household / Highest Earner? Yes ? NoAnnual Gross Household Income (include all sources)? Less than or equal to $10,000 ? $10,001 to $20,000? $20,001 to $30,000? $30,001 to $40,000? $40,001 to $50,000? $50,001 to $60,000? $60,001 to $70,000? $70,001 to $80,000? $80,001 to $90,000? $90,001 to $100,000? $100,001 to $150,000? over $150,000Household Size (include yourself)Age 18 or Over:Under Age 18:Single Parent with Child(ren) Under 18 Living at Home? Yes ? NoEmployment Status (check all that apply)? Self-Employed Full-Time ? Self-Employed Part-Time ? Employed by Someone Else Full-Time? Employed by Someone Else Part-Time ? Homemaker? Retired? UnemployedDo you have a business plan?? Yes - Completed ? Yes – In Progress? No – Not StartedWhat type of childcare business are you trying to open?? Home based ? Center based? Already openAre you currently in business?? Yes ? No If no, skip to Section 3: Terms and Conditions.If in business, have you done any of the following?? Completed Required Registrations? Obtained a Tax ID ? Enrolled children ? Incurred a business expense? Compensated an employee/contractor ? Acquired debt/equity capital to pursue business operations? None of the above6475095225425Region:_____00Region:_____Section 2: Business Information If you own multiple businesses, complete this form for the business you are seeking assistance with.Business NameBusiness Start DateIs this your primary business?? Yes ? NoWhat is your relationship to this business?? Owner ? Employee – Position:% Female Ownership? 0% ? 1-50% ? 51-100%Business Location? Home Based ? Commercial Space Business AddressCityStateZipEmailPhone NumberWebsiteBusiness Social Media HandlesFacebookLinkedInTwitter@Instagram@Have you registered as a business?? Sole Proprietorship ? LLC ? Partnership? C-Corporation ? S-Corporation? Benefit Corporation ? Non-Profit ? I have not yet registered as a businessType of Child Care Business ? Family Home (DCFH)? Group Home (DCGH)? Child Care Center (DCCC) ? Youth Camp? Board of Education? Exempt (DCEX) ? Unlicensed by OEC? Other – specify:OEC License # ? I am exempt or unlicensedProgram Capacity (complete for your type of program)Family HomeUnder Age 2Age 2 to Kindergarten School AgeGroup Home / Child Care CenterUnder Age 3 Age 3 and UpNumber of Currently Enrolled ChildrenBusiness Accreditations and Certifications? NAEYC ? NAFCC ? 8(a) Certified? Certified Women-Owned Business? Certified Minority-Owned Business? None of the aboveMember of a Child Care Provider Resource Agency? Staffed Family Child Care Network (SFCCN) ? Accreditation Quality Improvement System (AQIS)? Regional Educational Service Center (RESC)Please specify agency:Employees (incl. yourself)# Full-Time:# Part-Time:# Seasonal:# Contractor/Temporary:For your last 12 months in business, what were your:Gross Revenue / Sales$Profits (+) / Losses (-)$Owner’s Draw / Salary (business income used for personal/household expenses) $Section 3: Terms and ConditionsAs a client of WBDC, a Small Business Administration (SBA) Resource Partner, I agree to participate in a survey designed to evaluate WBDC and/or SBA services, if selected. I permit WBDC to share my name, address, telephone number and email address with the SBA for this purpose. Any information disclosed is kept confidential.? Yes? NoI certify that the above information is accurate. In consideration of the technical assistance and/or counseling provided to me, I waive all claims against WBDC, its personnel and any and all employees, agents, affiliates and third parties acting on behalf of or in conjunction with WBDC, arising from this assistance. I also waive all claims against SBA personnel, and that of its Resource Partners arising from furnishing management or technical assistance.Applicant Signature:Date:649224083820Region:_____00Region:_____ ................
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