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?
Name of the facility:
Benefits or public assistance received within the last year
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
Format: (000) 000-0000.
Which gender do you most identify with?
Which best describes your race/ethnicity- select all that apply:
Email
example@example.com
What is your income range:
What education level have you completed:
If you answered "other" above please describe:
Employment:
What goals do you have? - Pick 3:
If you answered "other" above please describe:
Which class session are interested in? (choose one)
Why are you interested in participating in the YWCA Great Lakes Bay Region's Women's Economic Empowerment Program?
optional_field
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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