GENESIS HUB INTAKE FORM

Hey! 

Thanks for your interest in Genesis. The information collected here will help us determine how we move forward with the creation of our new Genesis space, who may be interested and how we can best service the needs of of diverse and talented innovative community. We want to know as much as possible about you so we can offer an amazing place and space to residence of the Genesis hub and program.

Please take 10 minutes to complete this intake form. We will follow up with you directly for next steps. 

Kind regards, 

The Genesis Team 

Name of your organization or business:

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* 1. Name of your organization or business:

Main contact person's name:

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* 2. Main contact person's name:

Main contact person's email:

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* 3. Main contact person's email:

Current Mailing address:

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* 4. Current Mailing address:

Website:

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* 5. Website:

My organization's legal structure is as a:

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* 7. My organization's legal structure is as a:

Your organizations' mission:

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* 8. Your organizations' mission:

How long has your project/business been operating?

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* 9. How long has your project/business been operating?

Describe your target audience:

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* 11. Describe your target audience:

What is the need for this work? *

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* 12. What is the need for this work? *

Briefly describe your product, programs or services *

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* 13. Briefly describe your product, programs or services *

Briefly describe your organization's impact to date and or measures of success  *

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* 14. Briefly describe your organization's impact to date and or measures of success  *

Do you currently have a board or a leadership group? If yes, please list the names and titles of all members:

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* 15. Do you currently have a board or a leadership group? If yes, please list the names and titles of all members:

Are you currently employed outside of your project/organization? *

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* 16. Are you currently employed outside of your project/organization? *

If yes, how many hours per week do you work outside of this project? Explain if you expect this to change in the next two years. *

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* 17. If yes, how many hours per week do you work outside of this project? Explain if you expect this to change in the next two years. *

Why do you want to participate in the Genesis: UJA Federation's Centre for Jewish Innovation?

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* 18. Why do you want to participate in the Genesis: UJA Federation's Centre for Jewish Innovation?

How many days per week will you require or desire a desk at the Genesis: UJA Federation's Centre for Jewish Innovation Hub? Also, how many staff will need a desk?

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* 19. How many days per week will you require or desire a desk at the Genesis: UJA Federation's Centre for Jewish Innovation Hub? Also, how many staff will need a desk?

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