What is your team or company name?*

Primary Contact Person*

Primary Contact's Email*

Primary Contact's Phone*

Please list the names of other team members and if available, a link to their LinkedIn profile.*

Please provide a 300 word (max) summary of your company:*

Which challenge would you like to address?*

Patient and family experience in the in-patient setting

Patient engagement in the out patient setting

When would you be pilot ready? (i.e. at what date could your pilot begin at BWH?)*

Does your company have a website, Facebook page, twitter handle, etc? Please provide links below.*

Are you available to pitch your company from 4-7PM on April 28th?*

Yes

No

Please attach a slide deck (8 slide maximum) that summarizes the following items: - overview of the problem or need area you're addressing

-description of your proposed solution or process

- value proposition of your solution or process

- overview of the team

- proposed plan for a BWH pilot including:

----pilot goals

----metrics

----workflow to use your solution or process

----personnel resources needed at BWH to help usher along your pilot*

Please list your funding history if anything beyond family/friends?*

Do you have a BWH employee on your team (note: this is not required)? Please list their name(s):