Agency referral

Agency Referral Form

Thank you for your interest in referring your client to Up With Women / Exponenti’elles! We want to make sure the program is a good experience and the right fit for your client. Please review our eligibility criteria and if you have any questions, please reach out at contact@upwithwomen.org

Eligibility criteria: Individuals who meet the following criteria are eligible to apply. There is an interview process to determine best fit.

Housing: The applicant has some kind of stable housing (transitional housing is considered stable housing.

Income: The applicant is earning or receiving some kind of regular income (social assistance, employment income, etc.) but with a current lived experience of poverty

(Note: income assessment is based on personal income only)

Health & Safety: The applicant has reached a point of stability in health and safety where they can commit to a year-long, intensive program.

Fluency: The applicant has an English or French proficiency of LINC 6 or higher

To note: The applicants must be 18+ but there is no upper age cap and seniors are welcome to apply. We have no education requirements and no immigration/status requirements, but the applicant must be living in Canada.

By completing this form, you agree to Up With Women's Privacy Policy

Applicant is 18 years of age or over?

YesNo

We are only able to accept applicants 18 years and older. Please consider encouraging your applicant to apply for the program again when they are 18.

Does the applicant consent to you submitting this referral form on their behalf?

YesNo

Unfortunately, we cannot accept the referral without the applicant consent.

ABOUT YOUR AGENCY

Agency Name

Agency City

Agency Postal Code

Your first name (or first name of referrer)

Your last name (or last name of referrer )

Your email (or email of referrer)

Your Title (or title of referrer)

Your phone number (or phone number of referrer)

ABOUT THE APPLICANT

Applicant first name

Applicant last name

Applicant email

Applicant phone number

Applicant Address (Street Number, Street Name)

City/Town

Province

Postal Code

Applicant preferred language:

How does the applicant prefer to be contacted?

PhoneEmail

Does the applicant have stable housing?

YesNo

If the applicant does not currently have stable housing, please explain. Note that we consider transitional housing to be stable housing.

Please tell us a little more about why you feel the applicant would be a good fit for the program.

By completing this application, I confirm that I have verified the information above. (Type in your full name as your digital signature)

Contact Information