Worker Coop Academy Team Application
DUE BY: 11:59pm June 14th, 2015
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POINT PERSON CONTACT INFORMATION
Please provide us with the contact info for one individual from your team to be the designated point person for the Academy.
First Name *
Last Name *
Application Date *
MM
/
DD
/
YYYY
Phone Number *
Email *
What's the best way to reach you? *
Project, Business, or Organization Name *
Please give us the name of your project, business, or organization.
Team Members
Please list the names of all your team members that will take part in the Worker Coop Academy.
PARTICIPANT GROUP
Please identify yourself as ONE of the following participant groups: *
TEAM DEMOGRAPHICS: Startups, Expanders, & Converters
If you identified your team as "Startup," "Expand," or "Convert," please answer the TEAM DEMOGRAPHICS questions to the best of your knowledge.
How many members of your team self-identify as the following:
1
2
3
4
5
Female
Male
Other
Clear selection
How many members of your team self-identify as the following:
Feel free to double count if members of your team self-identify as multiple races.
1
2
3
4
5
African American or Black
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaskan Native
White or Caucasian 
Other
Clear selection
Do members of your team make less than $18 per hour?
Clear selection
Are members from your team Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?
Clear selection
FINANCIAL: Developers
Please answer this section if you identified yourself or your team as "Develop."
On average, do the populations you work with make at or below $18 per hour?
Do the populations you work with receive any of the following?
SCHEDULING ASSISTANCE
Will any members of your team be unable to attend Academy classes if childcare is not provided? *
We are trying to assess whether childcare will be a barrier to participation in the Worker Coop Academy for members of your team.
Do any members of your team have physical disabilities that we should be aware of? If so, what are they?
In finding spaces to hold our classes, we want to make sure that we accommodate all of our participant's needs.
Will any members of your team be unable to participate effectively in Academy classes if the classes are conducted in English?
If so, what is the primary language of those team members?
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