Share with us, a little about yourself...

We promise not to be intrusive.  We just want to know who you are and where you want to go.  This will help us navigate you on your journey to your next safe house. 

Question Title

* 1. Contact Information

Question Title

* 2. What is the highest level of education you have completed?

Question Title

* 3. How confident are you in...

  Not Confident Somewhat Confident Confident Very Confident
Your Ability to Succeed and Accomplish Your Goals
Knowing and Understanding Your Purpose
Your Ability to Stay Motivated
Your Time Management Skills
Your Belief System (Faith)
Your Ability to Stay Focused (Limit Distractions)
Your Support Systems (Network, Family, etc.)
Your Ability to Make Sound and Timely Decisions
Your Ability to Advocate for Yourself
Your Ability to Effectively Communicate (Verbally and Written)

Question Title

* 4. Complete this sentence.  "This Course Helped Me ( _______________ )..."

Question Title

* 5. This course helped me remove the following barriers (Check all that apply)

Question Title

* 6. If you could change ONE thing about the Great Escape Course, what would it be?

Question Title

* 7. Please rate the course based on the following:

  Satisfactory Needs Improvement Good Great
Marketing Appeal
Communication to Students
Accessing Documents
Course Content
Course Length of TIme
Course Time of Day
Course Outcomes

Question Title

* 8. How can we improve the Great Escape Course?  Be as specific or broad as you desire.  If you scored a course area above "satisfactory"  or "needs improvement", what exactly should we improve.  (i.e. make documents a pdf and email versus the flipping book...)

Question Title

* 9. Written Testimony: 

Please write a brief testimony (1 to 3 sentences max) as to why other women like you should take this course.

Question Title

* 10. Photo Upload (Optional)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

Question Title

* 11. The following disclaimer is for the information contained in this questionnaire only.  The prior personal information you have shared with us will not be divulged.  We may use certain general remarks as a whole to show providers the barriers you face, but we will never say you personally stated that you faced them. 

TESTIMONIAL AND PHOTO RELEASE FORM:

In good faith and valuable consideration, I, grant Brilloinaires and its agents the right to use my name, information, photographs, images, story, and/or testimonial, in whole or in part, and without restriction as to changes or alterations. The rights granted herein shall extend in perpetuity, unless revoked in writing to Brillionaires by me, throughout the world and for any purpose whatsoever, including without limitation for marketing and advertising purposes of Brillionaires, and in any and all media, including without limitation on the Brillionaires website.

I acknowledge that Brillionaires has no obligation to return any photographs or images to me. I hereby RELEASE, WAIVE and FOREVER DISCHARGE any and all claims arising out of, or in connection with, such use by Brillionaires. 

I hereby warrant and represent that I am at least 18 years of age and have the right to contract in my own name. I have read the above Release and am fully familiar with the contents thereof. This Release contains the entire agreement between the parties hereto as to the subject matter contained herein.

T