Enrollment Form for Driven 2 Success - Updated
Far Eastside Get A Round
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Email *
First Name *
Last Name
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Street Address *Note: Any member of this address can use vouchers on your account.
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Zip Code
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County
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Date of Birth
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Phone Number
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Text messages okay?
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For EH Study clients, please add your client number below. If not, please write "N/A" *
Gender
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Preferred language?
Clear selection
Race *
Ethnicity
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Marital Status
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Highest Grade Completed
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Are you working?
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If working, name of employer?
Emergency Contact Name
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Relationship to Emergency Contact
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Emergency Contact Phone Number
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How many are in your household (include yourself and ALL people who live in the household)? *Give the number of Adults, teens and children. For example, 2 adults, 0 teens, 4 children
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How old are you? (Pick the range)
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If rider is a youth, how are they related to you? (Type "N/A" if this doesn't apply to you.)
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If rider is a youth, what school do they attend? (Type "N/A" if this doesn't apply to you.)
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Total Annual Household Income (How much did your HOUSEHOLD make last year?):
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How much is your rent/mortgage payment?
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How much have you made in the last three months?
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MEDIA RELEASE: I give permission for my family member's images to be included in any promotional /media resources related to Pathway Resource Center including printed brochures, flyers, Pathway Resource Center website, social media pages or photos including press releases to local media. I also give permission for my contact information to be entered into the SMS service chosen by Pathway Resource Center in order to be kept up-to-date about pertinent information in reference to Driven 2 Success.  Pathway Resource Center will not sale my information to any third party company.  Pathway Resource Center will not identify family members by name.
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DATA SHARING: I give permission for Pathway Resource Center to share data with IndyGo and United Way of Central Indiana for program and outcome data collection purposes. My name and personal information will not be shared.
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EMERGENCY TREATMENT: I hereby give permission to the medical personnel selected by Pathway Resource Center staff to order X-rays, routine tests and treatment for me and, in the event that I am not able to communicate, and my emergency contact(s) cannot be reached. Additionally, I hereby give permission to the attending physician to hospitalize, order injection(s), order anesthesia, order surgery, or otherwise secure proper treatment for me. I understand that I will be fully responsible for any costs of such treatment, even if not covered by insurance.
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CLIENT CONFIDENTIALITY: I understand that Pathway Resource Center values the privacy of all individuals and families we serve and that all information given to Pathway Resource Center will be held in strict confidence and released based on these permissions unless authorized by the individual for disclosure or a court order is issued requiring the release of specific information.
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GRIEVANCE POLICY: I understand I have the right to receive services in a professional and respectful manner and that riders who feel that they have a complaint or grievance can take one or more of the following actions: report the incident/complaint to the Program Manager, request a review by the Executive Director and/or request a review by the Pathway Resource Center Board President.
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[REQUIRED] TRANSPORTATION: I understand that only licensed and qualified personnel will operate Pathway Resource Center vehicles. I agree to release the Pathway Resource Center, IndyGo, United Way,  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.
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MINOR CONSENT: I confirm that this rider is older than 13 years of age and younger than 18 years of age.  I am granting permission for this rider to use pre-paid vouchers and services for Driven 2 Success as transportation to and from school only without a parent or guardian present.
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PETS: I understand that no pets are allowed on the Driven 2 Success transportation service except certified service animals.  
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[REQUIRED] NO ALCOHOL/DRUGS/VIOLENCE/WEAPONS: Driven 2 Success has a zero-tolerance policy on the use of drugs and alcohol by drivers and passengers and on the use of violence or weapons. Service may be refused if a rider is suspected or proven to be under the influence of drugs and/or alcohol or carrying a weapon.
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Would you like to speak with the Family Advocate about other resources and services available to you?
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How did you hear about D2S?
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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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Final Notes: You must complete an enrollment form for each member of your family that will ride Driven 2 Success. You only need to enroll ONE time.  Your next step is to go back to the home page on www.driven2success.info and purchase your first voucher!
YOU ONLY HAVE TO COMPLETE THIS ENROLLMENT FORM ONE TIME
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