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Join Our Mission
Contact Us
Submit Referral
Referral Form
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Referred Participant Information
*** If the participant you are referring is a minor, please note that a guardian will need to accompany them on the shopping trip.
Participant Name
*
First
Last
Participant Phone Number
*
SMS/MMS Consent
I consent to receive text messages
By checking this box, you consent to receive text messages from us regarding your interactions with us and other relevant updates. Message and data rates may apply. You can opt-out anytime by replying STOP.
Participant Primary Language
*
-- Select --
English
Spanish
Other
Participant Current Living Situation?
*
-- Select --
Shelter
With Family/Friend
Apartment/Home
Are There Children in the Home?
*
-- Select --
Yes
No
Referral Partner Information
PLEASE NOTE
: to refer a participant, you must be an approved referral partner.
Referral Partner Name
*
First
Last
Referral Partner Organization
*
Referral Partner Phone Number
*
Referral Partner Email
*
Length of Time Participant Has Been Involved With Your Organization
*
Dignity Program
Choose the Dignity program that best reflects your referred participant's most immediate need.
Dignity Home
: household essentials for kitchen, bedroom, and bathroom.
Dignity Threads
: clothing, shoes, and accessories for employment.
Dignity Kids
: crib, car seat, stroller, high chair, and diapers/wipes.
Choosing the program that aligns most closely with your referred participants current circumstances allows us to provide a meaningful and personalized shopping experience.
Choose one of the following programs:
Dignity Home
Dignity Threads
Dignity Kids
Dignity Home (Household Items)
Select the Household Items Needed at this Time:
Household items (Kitchen, Bathroom, Bedroom)
Cleaning Supplies
Other (Please Note: No Food or Furniture)
Dignity Threads (Clothing Items)
Select the Job Related Clothing Items Needed at this Time:
Scrubs
Dress Clothing
Shoes
Work Boots
Other
Dignity Kids (Children's Items)
Select the Children's Items Needed at this Time:
Crib
Car Seat
High Chair
Baby Gate
Bed Safety Rail
Diapers/Wipes
Other
Additional Information
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Comments
This field is for validation purposes and should be left unchanged.
