First Name *

Last Name *

Email *

Email (Confirmation) *

Phone *

Address 1 *

Address 2

City *

State/Province *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming - Select Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Zip/Postal *

Country *
- Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentine Republic Armenia Aruba Australia Austria Azerbaijan Azores Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Polynesia Gabon 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 Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati 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 Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S Georgia Sandwich Islands Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent The Grenadines San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan, Rc Tajikistan Tanzania Thailand The Bahamas The Congo Togolese Republic Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis and Futuna Western Sahara Western Samoa Yemen Zambia Zimbabwe

Please indicate any dietary restrictions you may have.

This is a grant funded program and the following questions are needed for reporting purposes.

Gender *
- Select Option Man Woman Non-binary Prefer not to answer

Ethnicity *
American Indian/Alaska Native
Asian/Hawaiian/Pacific Islander
Black
Hispanic or Latino (All races)
Unknown/Unreported
White (Non-Hispanic)
Not listed Please specify a value for Ethnicity

Select your age group: *
- Select Option 18-24 25-34 35-44 45-54 55-64 65+ Prefer not to answer

I confirming that I am 18 years or older to participant in this program and to be eligible to pitch. *
- Select Option Yes No

Select the highest degree or level of school you have completed: *
- Select Option High school or equivalent Technical or occupational certificate Some college coursework completed Associate degree Bachelor’s degree Master’s degree Doctorate Professional Not listed Please specify a value for Select the highest degree or level of school you have completed:

Select your U.S. Military Service Status: *
On active military duty
Veteran of the U.S. armed forces
Reserves or National Guard
I am a spouse of a U.S. active duty service member or Veteran
Not listed Please specify a value for Select your U.S. Military Service Status:

Are you a veteran with a disability? *
- Select Option Yes, I have a disability or have a history/record of having a disability No, I don't have a disability or have a history/record of having a disability Prefer not to answer

The Battle Creek Cohort will be held on Mondays at 6 p.m. starting September 11th - December 4th, 2023. The final pitch night will be held on Monday, December 4th, 2023, at 5 p.m. for the showcase and pitches begin at 6 p.m.

What is your business/idea name? *

If applicable, provide your business website or social media page

What is your idea? Please be brief. *
Please enter at most 150 words. You currently have:

What problem are you trying to solve?
Please enter at most 150 words. You currently have:

What have you done to test your idea?
Please enter at most 150 words. You currently have:

What kind of help do you need?
Please enter at most 150 words. You currently have:

Check those that apply to you:
I have filed a patent
I have developed a prototype
Being paired with a University student sounds interesting to me
I have had my idea- in one form or another- for more than a year

How do you currently spend your time and energy?
Please enter at most 100 words. You currently have:

Past school or work experience that you wish to mention?
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Tell us about any experience as an entrepreneur or working with entrepreneurs.
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Tell us about any experiences with marketing, sales, and/or business management.
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What strengths and skills do you bring to this workshop? *
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What do you hope to gain from this workshop? *
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Tell us about anything else that you'd like us to know!
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