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Join the Waitlist. BIPOC Women Leaders Coaching Program Intake Questionnaire

Interested in joining the BIPOC Women Leaders Coaching Program? Start here. 

Filling out this form will help us understand more about you in order to better craft experiences to support you and this community overall. *We ask White individuals who are allies to preserve this space for the BIPOC community.*

Click the button below to start.

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Question 1 of 14

First Name

Question 2 of 14

Last Name

Question 3 of 14

Preferred Name to go by:

Question 4 of 14

How did you hear about the BIPOC Women Leaders Coaching Program?

Question 5 of 14

Your Email (the email you will use to sign-up for the BIPOC Women Leaders Coaching Program): 

Question 6 of 14

Race (choose all that apply): 

(Select all that apply)
A

American Indian, Alaskan Native

B

Asian

C

Black, African-American

D

Latine/Hispanic

E

Multiracial

F

Native Hawaiian, Pacific Islander

G

White

H

Other (please answer below if other)

Question 7 of 14

If you answered Other in the previous question, please answer here. If this doesn't apply to you, put N/A. 

Question 8 of 14

Pronouns (I.e. she/her/hers, he/him/his, they/them/theirs, etc.):             https://www.mypronouns.org/what-and-why

Question 9 of 14

Gender Identity: 

A

Cisgender female

B

Cisgender male

C

Gender non-binary

D

Gender fluid

E

Genderqueer

F

Transgender

G

Trans woman

H

Trans man

I

Other (please answer below if other)

Question 10 of 14

If you answered Other in the previous question, please answer here. If this doesn't apply to you, put N/A. 

Question 11 of 14

Are there any accommodations you will need to participate in this program, that we should be aware of?

Question 12 of 14

Why are you interested in the BIPOC Women Leaders Coaching Program? Please share 3-4 sentences. 

Question 13 of 14

Do you have a promo code? If not, enter N/A. 

Question 14 of 14

Any other questions or comments? If this doesn't apply to you, put N/A. 

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