Formulaire de candidature

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1. CONTACT INFORMATION

1.1. Name of the project*

1.2. Name of the company (if applicable)

1.3. VAT number of the company (if applicable)

1.4. Creation date of the company (if applicable)

1.5. Address of the company (if applicable)

1.6. Contact person’s first name and last name*

First Name Last Name

1.7. E-mail address*

1.8. Telephone number*

1.9. Postal code of the contact person*

1.10. Billing Address*

Address City ZIP / Postal Country

2. YOUR PROJECT

2.1. Short summary of your project.*

Please write a short summary of your project. The summary will be used by lifetech on the MedTech Accelerator webpage as well as for presenting participants and solutions of the 2023 cohort to external organizations. Please include the following : the need you solve, your market, your solution and the innovation as well as the technical readiness (if applicable). (500 words max).

2.2. Member of your team*

List the members of your team, their background (researcher, healthcare professional, entrepreneur, etc.), their role in the company/project, the time they dedicate to the project per week. Please include yourself as a member of the team. One person per line. If you don’t have a team yet, please mention if you are looking for specific profiles to complete your team ? If you’re not looking for anyone extra, please elaborate why.

2.4. Main obstacles*

What are the 3 main obstacles you face in your project?

2.3. Financial resources*

In order to ensure the sustainability of your project next to your participation to the MedTech Accelerator®, please elaborate on the financial resources you have to invest in your project (for building a prototype, developing a software, conducting a feasibility study, etc.).

2.5. Please tick the boxes that are linked to the work you have already achieved (one or more checkboxes)*

I have looked at my customers’ need, I understand deeply what causes the problem and how big it is. I know what is the “job-to-be-done” .

I have looked at my clients’ segmentation, the types of customers I might have.

I have an idea of how big the market could be, in Belgium and internationally.

I have an general idea of my competitors.

I have tested the concept of my solution with a target group.

I have an idea about how I could generate income.

I have listed the technical hypotheses of my solution.

I have already tested the hypotheses.

I already done few components in labs/experimental environment.

I already done a first prototype (visuals, demo).

None of this above

3. YOUR ACCELERATION JOURNEY

3.1. What are the implications for you of becoming an entrepreneur?*

3.2. Why are you joining the MedTech Accelerator® (max 3 reasons)?*

3.3. Have you already received any other support for this project? If yes, by whom?*

4. LIFETECH VISIBILITY

4.1. How did you get to know about the MedTech Accelerator?*

Newsletter

Peers

Google Search

Autre

4.2. Have you been in contact with lifetech.brussels before?*

Yes

5. VIDEO

Please upload here below your 1 min video presenting your motivation to join the MedTech Accelerator® (any format is welcome - video you’ve made with your phone, a slide presentation with voice over, etc.). If you have any issues with the upload of the file, send it via a third party service (WeTransfer...) to the email address hlinsmeau@hub.brussels

Upload video

Types de fichiers acceptés : mp4, mov, avi, mpeg, mpg, wmv, Taille max. des fichiers : 5 MB.

6. CONSENT FORM

6.1. By filling in this form, I accept to pay to hub.brussels the registration fees (price is mentioned above) and the refundable guarantee of € 300 (prices are mentioned at the first page of this form).*

Yes

6.2. Pictures will be taken during the program and the sessions may be recorded for press & social media coverage purposes.*

I agree to appear on pictures/videos

I disagree to appear on pictures/videos

6.3. All the information (written and verbal) exchanged with the other participants throughout the MedTech Accelerator® program should be considered confidential and proprietary of the discloser. All confidential information should not be disclosed to anyone without the written consent of the discloser.*

I agree

6.4. By submitting this form, I accept that the information entered will be used by lifetech.brussels for the smooth running of the acceleration program in accordance with their Privacy Policy.*

To know and exercise your rights, including withdrawal of your consent to use the data collected by this form, please consult our privacy policy on hub.brussels.

I agree

Phone

Ce champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.

MedTech Accelerator® 2023

1. CONTACT INFORMATION

2. YOUR PROJECT

3. YOUR ACCELERATION JOURNEY

4. LIFETECH VISIBILITY

5. VIDEO

6. CONSENT FORM