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MLK Center Intake Form

The survey will take approximately 5 minutes to complete. If you are new to the MLK Center, please use this form to register for the first time. You must live in one of the neighborhoods we serve: Butler Tarkington, Meridian Kessler, Mapleton Fall Creek, or Crown Hill (Boundaries: North/56th Street | South/29th Street | East Monon/Fall Creek | West/MLK/Michigan Rd) OR have a child that attends IPS school #43 to be eligible for services. If you do not live in one of the neighborhoods listed above, or have a child at IPS school #43, you will not receive a response. If you do live in the area we serve, a wellness coach will contact you to follow-up within two weeks. If you are already working with us, please contact the front desk or a coach directly at 317-923-4581

First NameLast Name

Date of Birth

Email AddressPhone Number

Street AddressZip Code

4620546208Other

Has the MLK Center assisted you before?

YesNoUnsure

Are you currently working with a Wellness Coach at MLK?

NoYes

What things do you need help with today?Rent or Utility Assistance (you will have to provide your current lease and/or a bill). Funding is limited and is not guaranteed.
Employment or Education Assistance (resume, job training, certification, etc.)
Midtown-Get-Around (our transportation program)
Financial Wellness (homeownership, credit building, budgeting, etc.)After School Program at #43 (elementary age)
After School Program at #43 (middle school age)
Mental Health or Emotional Wellness (individual or group counseling)
Best Buy Teen Tech Center (drop in spot after school)
40 West Digital (videography program for 17-24 year old)
Other

If you are seeking utility assistance, are your utilities currently disconnected OR you have a disconnect notice?

YesNoNot Applicable

What is the date of disconnection?

If you are seeking rental assistance, has an eviction been filed? You MUST have a court date and case number.

YesNo

When is your court date?

Do you have a child attending IPS School #43?
YesNo

Race

African American or Black
Caucasian or White
American Indian or Alaskan Native
Asian
Hawaiian or Pacific Islander
African
Two or More Races
Other

Gender

FemaleMaleNon-binary

Ethnicity

HispanicNon-Hispanic

Marital Status

DivorcedDomestic Partner
Married
Single (Never Married)
Separated
Widowed

About how much does your household earn in a year?
What is the total number of people living in your household?

Employment Status

Employed Full-Time (35 hours or more each week)
Employed Part-Time (Less than 35 hours each week)
Unemployed (Seeking Employment)
Not in the workforce (homemaker, disabled, retired)
Other

Highest Level Of Education Completed

Less than high school
High School/GED
Some College
Two-Year Degree
Technical Degree/Certification
Four-Year Degree
Masters Level Degree
Doctorate Degree

Do you know if your voter registration is up-to-date?

Yes, I'm registered and the information is current!
No, I need to update my voter registration and will visit indianavoters.in.gov
No, I need to update my voter registration and would like help.I need to register to vote and would like help.Prefer not to answer

Anything else we should know to be helpful?

Authorization, Acknowledgement and Release

Media Release: I give permission for my family's image to be included in any promotional/media resources related to MLK Center, including printed brochures, flyers, website, social media pages or photos included with press releases to local media. MLK Center will not identify children by name.

YesOpt OutData Sharing: I give my permission for MLK Center to collaborate with my child’s school system, in securing copies of grades, assessments, attendance, discipline referral, suspension information, and school counselor’s reports, to help MLK Center staff support my child’s educational process. I give my permission to share data with IPS and United Way of Central Indiana for program and outcome data collection purposes.
YesOpt OutClient 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, or minor’s parent or guardian, for disclosure or a court order is issued requiring the release of specific information.
I acknowledge I have read the above statementGrievance Policy: You have the right to receive services in a professional and respectful manner. Anyone who feels 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 within 2 business days.
(2) If parents 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 the information.
(3) If parents 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 14 business days of completing a review.
I acknowledge I have read the above statementTransportation: 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.
I acknowledge I have read and agree with the above statement

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

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