*First Name:
*Last Name:
Business/Organization Name:
*Mailing Address:
*City:
- Select -
100 Mile House 108 Mile Ranch 150 Mile House 70 Mile House Abbotsford Agassiz Ainsworth Hotsprings Aiyansh Aldergrove Alert Bay Alexis Creek Alkali Lake Altona Anahim Lake Anglemont Anmore Annacis Island Argenta Armstrong Arras Ashcroft Aspen Grove Athalmere Atlin Avola Baldonnel Balfour Bamfield Barkerville Barriere Bear Lake Beaverdale Beaverdell Belcarra Bella Bella Bella Coola Big Lake Black Creek Blind Bay Blind Channel Blubber Bay Blue River Boston Bar Boswell Bowen Island Bowser Brackendale Brentwood Bay Brideville Bridge Lake Brisco Brittania Beach Brookmere Buffalo Creek Buick Burnaby Burns Lake Burton Cache Creek Campbell Island Campbell River Canal Flats Canim Lake Canoe Canyon Cassidy Castlegar Cawston Cecil Lake Cedar Cedarvale Celista Central Saanich Charlie Lake Chase Chemainus Chetwynd Chilanko Forks Chilliwack Christina Lake Clayhurst Clearbrook Clearwater Clinton Cloverdale Coal Harbour Coalmont Cobble Hill Coldstream Colwood Comox Coombs Coquitlam Cortes Island Courtenay Cowichan Bay Cranbrook Crawford Bay Crescent Spur Crescent Valley Creston Crofton Cultus Lake Cumberland Curzon D'Arcy Darfield Dawson Creek Dawson Landing Dease Lake Delta Denman Island DeRoche Desroche Dewdney Dog Creek Dome Creek Douglas Lake Duncan Dunster Eagle Bay Eagle Creek Earls Cove Edgewater Edgewood Egmont Elkford Elko Endako Enderby Erickson Errington Esquimalt Fairmount Hotsprings Falkland Fanny Bay Farmington Fauquier Fernie Field Forest Grove Fort Fraser Fort Langley Fort Nelson Fort St. James Fort St. John Fort Steele Francois Lake Fraser Lake Fruitvale Fulford Gabriola Galiano Island Galloway Gang Ranch Garden Bay Garibaldi Highlands Genelle Germansen Landing Gibsons Gilles Bay Gitanmaax Gitanyow Gitsegukla Gitwangak Gitwinksihlwk Glen Vowell Gold River Goldbridge Golden Goodlow Grand Forks Granisle Granthams Landing Grasmere Gray Creek Greenville Greenwood Grindrod Groundbirch Gulf Islands Hagensborg Hagwilget Halfmoon Bay Hanceville Haney Harrison Hot Springs Harrison Mills Harrogate Hartley Bay Hazelton Hedley Hefley Creek Heriot Bay Hixon Holberg Honeymoon Bay Hope Hornby Island Horsefly Houston Hudson's Hope Huntingdon Iax Kw'alaams Invermere Iskut Jaffray Joe Rich-Ellison Jordan River Juskatla Kaleden Kamloops Kaslo Keats Island Kelowna Kemano Keremeos Kimberley Kincolith Kingcome Inlet Kingsgate Kispiox Kitchener Kitimat Kitimat Village Kitkatla Kitselas Kitsumkalum Kitwanga Kleena Kleene Klemtu Knutsford Koksilah Kootenay Bay Kuper Island Kyuquot Lac La Hache Lac Le Jeune Ladner Ladysmith Lake Country Lake Cowichan Lake Errock Lakeview Heights Langley Lantzville Lasqueti Lavington Lazo Likely Lillooet Lindell Beach Lions Bay Lister Little Fort Logan Lake Lone Butte Longworth Louis Creek Lower Nicola Lumby Lund Lytton MacKenzie Madeira Park Mahood Falls Malahat Malakwa Malkawa Manning Park Manson Creek Mansons Landing Maple Bay Maple Ridge Mara Marysville Mason's Landing Masset Matsqui Mayne Island McBride McClure McLeese Lake McLeod Lake Meadow Creek Merritt Merville Mesachie Metchosin Meziadin Lake Mica Creek Midway Mill Bay Milner Minstrel Island Mission Moberly Lake Monte Creek Monte Lake Montney Montrose Moricetown Mount Currie Mount Lehman Moyie Muncho Lake Nakusp Namu Nanaimo Nanoose Bay Naramata Nazko Nelson Nemiah Valley New Aiyansh New Denver New Hazelton New Westminster Newton Nimpo Lake North Burnaby North Cowichan North Delta North Hazelton North Pine North Saanich North Shuswap North Surrey North Thompson North Vancouver Oak Bay Ocean Falls Okanagan Centre Okanagan Falls Oliver Ooona River Osoyoos Oyama Oyama Panorama Parksville Parson Pavilion Peachland Pemberton Pender Island Penny Penticton Pinanton Lake Pink Mountain Pitt Meadows Port Alberni Port Alice Port Clements Port Coquitlam Port Edward Port Hardy Port McNeill Port Mellon Port Moody Port Neville Port Renfrew Port Simpson Pouce Coupe Powell River Prespatou Prince George Prince Rupert Princeton Pritchard Procter Progress Prophet River Quadra Island Qualicum Beach Quathiaski Cove Quatsino Queen Charlotte City Queen Charlotte Islands Quesnel Quilchena Radium Hot Springs Refuge Cove Revelstoke Richmond Riondel Riske Creek Rivers Inlet Roberts Creek Robson Rock Creek Rolla Rose Prairie Rosedale Rossland Royston Rutland Saanich Saanichton Saanichtown Salmo Salmon Arm Salmon Valley Salt Spring Island Saltery Bay Sanspit Sardis Saturna Island Savona Sayward Sechelt Seton Portage Sewell Inlet Shalalth Shawnigan Lake Sicamous Sidney Silver Star Mountain Silverton Simoon Sound Sinclair Mills Sirdar Skidegate Skookumchuk Slocan Slocan Park Smithers Sointula Sooke Sorrento South Delta South Hazelton South Saanich South Slocan South Surrey Southbank Southview Spallumcheen Sparwood Spenses Bridge Spillimacheen Spuzzum Squamish Steveston Stewart Stuart Island Sullivan Bay Summerland Summit Lake Sunset Prairie Surge Narrows Surrey Ta Ta Creek Tahsis Takla Landing Takysie Lake Tappen Tatla Lake Tatlayoko Lake Taylor Telegraph Creek Telegraph Crove Telkwa Terrace Texada Island Thetis Island Thornhill Tiell Toad River Tofino Tomslake Topley Trail Tsawassen Tulameen Tumbler Ridge Two Mile Ucluelet Union Bay Upper Fraser Valemount Vallican Van Anda Vananda Vancouver Vanderhoof Vavenby Vernon Victoria Waglisla Walachin Wardner Ware Warfield Wasa Wells West Vancouver Westbank Westbridge Westholme Westwold Whaleton Whalley Whistler White Rock Whonnock Williams Lake Willow River Windermere Winfield Winlaw Winter Harbour Wonowon Woss Wynndel Yahk Yale Yarrow Ymir Youbou Zeballos
*Postal Code:
*Contact Telephone: (Enter as xxx-xxx-xxxx)
*Primary E-mail:
For statistical purposes, please indicate if you are: Aboriginal - If yes please select one:
First Nations
Métis
Inuit
Immigrant - If so, how many years have you been in Canada? A Person with a Disability
*Would you like to receive the Women’s Enterprise Centre monthly newsletter and small business updates? Yes
No
Section 2 – Program Information:
*All participants must be at least 19 years of age. Please indicate your birth date: (Enter as DD/MM/YYYY)
Women’s Enterprise Centre has received funding to help women identify and remove economic, geographic and social/cultural barriers that prevent them from fully participating in the economic prosperity of their community.
*Please select ALL the barriers that apply in your case.
Economic
Can't afford communication & leadership skills training
Credit history
Industry layoffs/downsizing
Lack of business finances
Lack of flexible, reliable, cost-effective child care
Limited career opportunities
Other: Explain
If other, please explain:
Geographic
Small community
Isolated community
Lack of local resources
Far from another support group
Other: Explain
If other, please explain:
Social/Cultural
Age
Accent/speech challenges
Cultural differences
Education level
Lack of mentoring/guidance
Lack of self-confidence
No formal leadership training
Visible minority
Other: Explain
If other, please explain:
*What do you hope to gain from participating in the Taking the Stage® Program related to leadership and decision-making?
- Select -
Build confidence
Clear written communication
Structure my thoughts when I speak
Improve presentation skills
Negotiate better
Prepare for a new leadership role
Qualify for a promotion
Understand cultural differences
- Select -
Build confidence
Clear written communication
Structure my thoughts when I speak
Improve presentation skills
Negotiate better
Prepare for a new leadership role
Qualify for a promotion
Understand cultural differences
*On a scale of 1 to 4, with 1 being low and 4 being high, how would you rate your confidence level in taking on new leadership roles within your business and/or community? one (low)
two
three
four (high)
*The Taking the Stage® Program, as offered by Women's Enterprise Centre, is designed specifically to help women in business situations. Business owner Potential business owner Employee of a business Other: Explain If other, please explain:
Please use this space to provide us with any additional comments about your leadership goals:
*How did you hear about Taking the Stage® offered by Women’s Enterprise Centre?
- Select -
Advertising
An event (e.g. seminar, workshop, tradeshow.)
Chamber of Commerce
Community Futures
Referral from government service
Women in Business Network
Women's Enterprise Centre Website
Word of mouth
Other
Section 3 – Bursary Application:
The cost of the Taking the Stage® Program is $150 per person. We have a limited number of bursaries available to cover this program fee.
To be eligible for a bursary you must be female and an aboriginal, immigrant, youth (19-34 years old) or entrepreneur in the first three years of business. Bursaries are awarded on an individual basis upon consideration of financial need and eligibility.
*Are you applying for a bursary? Yes
No
If no, you will be required to pay the $150 fee after we confirm your successful application.
* Please indicate your eligibility (select all that apply)Aboriginal Immigrant Youth (19-34 years old) Entrepreneur in the first three years of business (You are not eligible if you were a Mentee in our mentoring program in 2009/10)
* Please identify your financial need (select all that apply)Household income less than $35,000 Unemployed/underemployed * Full-time student
*Underemployed If you cannot obtain full-time employment or are working at jobs that you are overqualified for. Underemployed can also mean "involuntary part-time" employment, or employment of a person on a part-time basis when full-time work is desired.
Are there any exceptional expenses/circumstances that will influence your financial need this year? Please explain.
WOMEN’S ENTERPRISE CENTRE
Collection and Use of Information
I have answered all questions on this form and certify that all information I have provided is complete and accurate.
I understand the Women's Enterprise Centre, through the Province of British Columbia, receives funding for this program from the federal government as a result of the Canada-BC Labour Market Agreement.
I understand that information I have provided on this form or that has been collected about me during my participation in this program will be forwarded to the Ministry of Advanced Education and Labour Market Development who is the provincial oversight for the Canada-BC Labour Market Agreement.
I understand the Ministry of Advanced Education and Labour Market Development is responsible for fulfilling reporting obligations under section 30 of the Canada-BC Labour Market Agreement, however, no personally identifiable information about me will be exchanged with the federal government to fulfill this requirement.
I consent to being contacted by the Ministry of Advanced Education and Labour Market Development (or its agent) at intervals and up to 12 months after completion of my participation in this program for the purpose of program evaluation.
Collection and Use of Information. All information is collected pursuant to section 26(c) of the Freedom of Information and Protection of Privacy Act. The information provided will be used for administrative and evaluation purposes of this program. If you have any questions about the use of this information, contact the Director of Labour Market Agreement, Ministry of Advanced Education and Labour Market Development, (250) 952-0642
If you have any questions, please contact our Taking the Stage® Coordinator at Women's Enterprise Centre, 1.800.643.7014 ext 110 or
.
