Referral Partner Application

Thank you for your interest in becoming an approved referral partner with Dignity Foundation. Referral partners are essential to ensuring participants are connected with our programs in a way that honors their dignity and meets their needs. This application helps us learn more about your organization and confirm alignment with our referral partner responsibilities.

"*" indicates required fields

Organization Information

Organization Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Website*

Primary Contact Information

Name*

First Last

Title/Role*

Phone*

Email*

Secondary Contact (optional)

First Last

About Your Organization

Briefly Describe Your Organization and Its Mission*

How Long Has Your Organization Been Operating?*

Population You Primarily Service (Age, Demographics, Special Needs, Etc.)*

Geographic Area Served*

Approximate Number of Clients Served Annually*

Referral Process

How Does Your Organization Identify Participants For Support?*

Approximately How Many Referrals Do You Anticipate Submitting Each Month?*

Are There Barriers or Considerations (Language, Transportation, Accessibility) We Should Know About?*

Agreement & Acknowledgment

By submitting this form, you acknowledge that, if approved as a referral partner, you agree to:

• Be an approved referral partner of Dignity Foundation.
• Confirm that participants meet Dignity Foundation’s eligibility criteria.
• Introduce and explain Dignity Foundation programming to participants before submitting a referral.
• Obtain participants’ verbal or written consent to share their information with Dignity Foundation.
• Provide accurate and complete information about participants’ needs and circumstances.
• Ensure participants understand that a Dignity Foundation representative will contact them to schedule their shopping trip.

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