Referral Form

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Referred Participant Information

* All referrals must come from approved Dignity Foundation referral partners. We appreciate your partnership in supporting those we serve.

** To become a referral partner, CLICK HERE to complete an application form.

*** 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

Total number of individuals living in household*

Name(s) and age(s) of ALL individuals living in household.*

Click '+' to add a new row

Full Name

Age

Participant Phone Number*

Participant Address*

Street Address City State ZIP Code

Eligibility Criteria*

To ensure that participants receive the greatest benefit from Dignity Foundation programs, referrals must meet the following criteria:

	Yes	No
Residency: Resides in Maricopa County
Referral Source: Referral is submitted by an approved referral partner
Program Engagement: Participant has been actively engaged in your program for a minimum of 4-6 months (unless otherwise approved by Dignity Foundation)
Household Status: Participant is in the process of establishing stable, independent housing

Participant Primary Language*

Housing Status*

Move-In Date (if applicable)

Transportation Needs*

Will the referred participant need transportation for the shopping trip?

Yes

Brief Background or Reason for Referral*

Referred Participant Information

Referral Partner Information

Dignity Program

Dignity Home (Household Items)

Dignity Threads (Clothing Items)

Dignity Kids (Baby and Children's Items)

Terms and Conditions