Enrollment Form for Midtown-Get-Around
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First Name *
Last Name *
Street Address *
Zip Code *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Email address *
Gender *
Race *
Ethnicity *
Marital Status *
Highest Grade Completed: *
Are you working? *
If working, name of employer?
Emergency Contact Name: *
Relationship  of Contact: *
Emergency Contact Phone Number: *
How many are in your household (include yourself)?   *
Give the number of Adults, teens and children. For example, 2 adults, 0 teens, 4 children
Total Annual Household Income ( How much did your HOUSEHOLD make last year?): *
How much have you made in the last three months? *
How much is your rent/mortgage payment? *
Authorizations *
Yes, I authorize
No, I do not authorize
MEDIA RELEASE: I give permission for my family member's images to be included in any promotional /media resources related to MLK Center including printed brochues, flyers, MLK Center website, social media pages or photos including press releases to local media. MLK Center will not identify family members by name.
DATA SHARING: I give permission for MLK Center to share data with United Way of Central Indiana for program and outcome data collection purposes. My name and personal information will not be shared.
CLIENT CONFIDENTIALITY: MLK Center values the privacy of all individuals and families we serve. All information given to MLK Center will be held in strict confidence and released based on these permissions unless we are authorized by the individual for disclosure or a court order is issued requiring the release of specific information.
[REQUIRED] GRIEVANCE POLICY: You have the right to receive services in a professional and respectful manner. Clients who feel that they have a complaint or grievance can follow the following procedure: (1) Report the incident/complaint to the Program Director for review. The Program Director is to provide a response withing 5 business days. (2) If clients still believe that the situation was not resolved, request a review by the Executive Director. The Executive Director will speak to all parties involved and provide a written response within 7 business days of completing a review of all information. (3) If clients still believe that the situation was not resolved, request a review by the MLK Center Board President. The Board President will review all information and provide a written response within 10 business days of completing a review.
[REQUIRED] TRANSPORTATION: I understand that only licensed and qualified personnel will operate MLK Center vehicles. I agree to release the MLK Center, IndyGo , its officers and directors, and staff from any and all claims of damages, demands or liabilities, which may arise as a result of my and my family's participation in the transportation program. [REQUIRED FOR TRANSPORTATION]
[REQUIRED] NO ALCOHOL/DRUGS/VIOLENCE/WEAPONS: Mid-Town-Get-A-Round has a zero-tolerance policy on the use of drugs and alcohol by drivers and passengers and on the use of violence or weapons.
Signature: By typing your name below, you certify that you are the client and you have the legal authority to make the representations and grant the authorizations contained herein. *
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