My Start-Up: Participant Registration Form

Section A: Applicant Information

Program Start Date

Applicant Full Name

Contact Number



Postal Code

Date of Birth

Age Group

Emergency Contact

Contact Number

Employment Status

Source of Income


Education History

Immigration Status

Do you have a valid S.I.N Number?

Referral Source


Section B: Business Overview

Tell us about your business or business idea. Please provide as much detail as possible regarding your business.

Do you have access to a computer?

Business Status

Industry Sector


Business Idea

What would be your product or service?

Who will be your customer?

Where would your business be located?

Are you interested in applying for low-interest business loan

What do you want to learn from this program?

Why have you not started a business?

Are you interested in participating in additional training if available?

Do you self-identify as a member of a designated group(s)?

We will be sharing this information with our funder, for the purpose of assessing and evaluating the effectiveness of our programs and services. Check all that apply.

Additional Information you would like to share.

Susan is a public speaker, educating people about the criminal justice system and legal rights. She exudes confidence and speaks with passion. It is hard to imagine that just a year ago, Susan was struggling with low self-esteem and was extremely shy. After a long history of incarceration, Susan was determined to change her life for the better. Susan joined the Peer Leadership program and developed public speaking skills, connected with positive role models and built her confidence. Susan is now a community educator, has re-connected with her family and is mentoring new members of the Peer Leadership program.