Martindale Brightwood COVID-19 Emergency Benefit Enrollment

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THE EDNA MARTIN CHRISTIAN CENTER (EMCC) AND PUBLIC ADVOCATES IN COMMUNITY RE-ENTRY (PACE) ARE WORKING COLLABORATIVELY TO PROVIDE CRITICAL EMERGENCY BASIC NEEDS TO RESIDENTS OF THE MARTINDALE BRIGHTWOOD COMMUNITY AND NEAR NORTH-EAST SIDE OF INDIANAPOLIS DURING THE COVID-19 CRISIS.

All personal information collected by the EMCC and PACE is protected by strict privacy policies. We will not share your personally-identifying information without written permission.

First Name *

Last Name *

Street Address *

Zipcode *

Preferred Phone Number *

Date of Birth *

YYYY

Gender *

Race *

Ethnicity *

Hispanic

Non-Hispanic

Marital Status *

Employment Status *

Highest Grade Level Achieved *

Gross Annual Household Income *

Number of Household Members *

Has your job been affected by COVID-19? *

Yes, my hours have been reduced

Yes, I have been laid off from my job

No, my job is unaffected by COVID-19

No, I wasn't working prior to the pandemic

Required

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