WEEP Referral Form

Women's Economic Empowerment Program Enrollment

Thank you for your interest in the YWCA GLBR! Completing this form will allow us to determine your eligibility for our programs. Don't worry; most women are accepted right away. Once we receive your information, we will reply by text and/or email within a few business days. Your individual responses are confidential and not published or shared with others (except in summary) without express permission.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Are you currently unhoused or living in a shelter/facility?*

YesNo
Name of the facility:
Benefits or public assistance received within the last year*

Public housing voucherSpecial Supplemental Nutrition Program for Women, Infants, Children (WIC)Supplemental Nutrition Assistance Program (SNAP)Supplemental security income (SSI)Temporary Assistance for Needy Families (TANF)None of the above
Street Address*
City*
Zip*
What county do you currently live in? Only residents of Bay, Midland and Saginaw Counties are eligible for our programs.*
Phone Number*
Which gender do you most identify with?*
Which best describes your race/ethnicity- select all that apply:*

White/European DescentBlack/African AmericanAmerican Indian/First PeoplesAsian American Pacific IslanderMiddle Eastern/North AfricanHispanic or LatinoPrefer not to answer
Email*
example@example.com
What is your income range:*

$0-$10,000$10,001-$20,000$20,001-$30,000$30,001-$40,000$40,001-$50,000$50,001-$60,000$60,001-$70,000$70,001-$80,000
What education level have you completed:*

Some High SchoolHigh School Diploma or GEDSome CollegeCollege DegreeTrade School or Certification ProgramAdvanced Degree (MD, JD, Master's Degree)Other
If you answered "other" above please describe:
Employment:*

Full TimePart TimeUnemployedTemporary or SeasonalRetired (Social Security income)Receiving Disability income (SSDI)
What goals do you have? - Pick 3:*

HousingEmploymentEducationTransportationPhysical or Mental HealthBudgeting/SavingsImproved Credit ScoreFinancial StabilityOther
If you answered "other" above please describe:
Which session are interested in? (choose one)*

Private Session: Moving Ahead (Financial Fundamentals) at URR Thursdays starting 11/06/25 (not open to public enrollment)Please contact me with info about future YWCA classes
Why are you interested in participating in the YWCA Great Lakes Bay Region's Women's Economic Empowerment Program?*
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Please verify below. If you have any difficulties, please call 989-894-9055 or write to us at kim@ywcaglbr.org*
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If you have any issues with this form call us 989-894-9055 (M-F 8:30-4:00pm) for assistance!
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Women's Economic Empowerment Program Enrollment

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