Enrollment Form for Midtown-Get-Around
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] EMERGENCY TREATMENT: I hereby give permission to the medical selected by MLK Center staff to order x-rays, routine tests and treatment for me, and, in the event I am not able to communicate or cannot be reached in an emergency, I hereby give permission to the physician selected by the Director to hospitalize, secure proper treatment for, and order injection(s) and/or surgery for me. I will be fully responsible for any costs of such treatment, even if not covered by insurance.
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. *
Submit
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