Indianapolis Urban League Online Registration Form

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Information Session In Person Thursday, May 11th at 11am

Email *

Empowering Communities, Changing Lives

Full Legal Name *

Phone Number *

Birth Date *

YYYY

Gender *

Female

Male

Gender Diverse

Other:

Race *

African American/Black

Caucasian/White

Two or More

American Indian/ Alaskan Native

Hawaiian/ Pacific Islander

Other:

Ethnicity *

Hispanic

Non-Hispanic

Total # of People in Household *

List all other household members and their date of birth for income consideration. *

Military Status *

Active Duty

Spouse of Active Duty

Veteran

Spouse of Veteran

Never Served

Highest Grade Completed *

High School Diploma

G.E.D.

Some College

Associates Degree

Bachelors Degree

Master's Degree

Completed Vocational Training

No Diploma

Employment Status *

Full Time

Part Time

Seeking Employment

I ____________________________ give permission for staff of The Indianapolis Urban League to sign my WAF application on my behalf. I understand that the Staff of the Indianapolis Urban League is not guaranteeing that I will receive assistance with my utility bill, but are only providing intake of my application.

Type your Full name to grant permission below:

Indianapolis Urban League collects basic information to meet reporting requirements of various funding sources. Your information is combined with information from other center participants and is not reported with your name attached to it. However, staff work as a team at the Urban League, so some information may be shared among Urban League staff in order to serve you. We pledge to do our best to maintain confidentiality. (I understand and agree) *

Yes

I have read this general release and confidentiality statement, and I agree to let the Indianapolis Urban League, Inc. share information as necessary to provide me with better service(s). I understand that this agreement will be in effect for the duration of my participation in services with the center. I further understand that upon my request this release of information and confidentiality can and will be amended. (I understand and agree) *

Yes

I hereby grant to the Indianapolis Urban League, its representatives, employees or agents the right to take photographs and videos of me and my property in connection with operations of the meetings, gatherings, classes and events. I grant the Indianapolis Urban League the rights to copyright and assign, transfer or publish photograph or video of me or my likeness for any lawful purpose. Publishing may be in printed or electronic form, may or may not include my name or business names. Examples of use include publicly, illustration, advertising and Web content. I have read and understand the above. *

Yes

The Indianapolis Urban League, Inc. is a not-for-profit organization. Through our annual reporting process, the Urban League is asked to share aggregated demographic data for those served by the centers’ many programs. The Urban League will only share aggregated demographic information with our funders and partners. The aggregated demographic information is not linked to any personally identifiable information that can used to identify any one person. Out of respect for our clients’ privacy, we present the option to opt in of the aggregate data sharing. ( I understand and agree) *

Yes

Signature *

Today's Date *

Thank you for completing this document we will be in contact with you if we have any additional questions or are needing you to provide additional information. *

Yes, I understand and have reviewed this entire form and have read the email sent with this link.

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