*Contact Information(Required.)

Name *

Company *

Current Title *

City/Town

State/Province

Email Address *

Phone Number *

*Is your company a Western Growers member?(Required.)

Yes

No

*Are you willing to commit to 3-5 hours every month for at least one year?(Required.)

Yes

No

*Is your company/manager in support of your participation in this program?(Required.)

Yes

No

*Years of professional experience in the agriculture industry:(Required.)

Why are you interested in the program?

Were you previously a part of the WG Women Program? 

Yes

No

Do you have any additional comments, feedback, or questions for the WG Women team?

*Please read the following statement:

By completing this application form, you agree to the goals and purpose of the WG Women program. Western Growers encourages an open exchange of information and ideas between members participating in the program. However, Western Growers/WG Women cannot and does not review such communications and does not guarantee or endorse the accuracy of any information exchanged between mentors and protégés. You agree that you will participate in the WG Women program in a manner consistent with the WG Women Mission. You further agree to completely release Western Growers/WG Women, and its directors, from all claims, judgements, demands, liabilities, and actions that you may have arising out of, or in any way relating to, your participation in the program. Western Growers and WG Women does not and shall not discriminate on the basis of race, color, religion, gender, gender expression, age, national origin, disability, marital status, sexual orientation, or military status, in any of its activities or operations.(Required.)

I agree with the above terms, conditions, and goals of the WG Women program.

*Electronic Signature(Required.)

Full Name

Date