Indianapolis Urban League

Virtual Session Workforce Development Online Registration Form

SECTION A – Personal Information

Your Name (Last, First, Middle Initial) (required)


Social Security Number (required)

Birth Date (required)

Address or P.O. Box (required)

Home Phone Number (required)

City (required)

State (required)

Zip Code (required)

Cell Phone Number (required)

E-mail Address (required)

Work Phone Number (required)

Emergency Contact (required)

Emergency Number (required)

Relationship To You (required)

Gender (required)

Ethnicity (required)

Disabled (required)

Race (required)

Marital Status (required)

SECTION B – Assistance Request Information

What are you interested in? (check all that apply) (required)
Education / TrainingFinancial Education / CounselingDigital Literacy/Computer InstructionIncome Supports / Public Benefits (rental / utility financial assistance, clothing, food)Health / WellnessJob Placement / Career DevelopmentOther

SECTION C – Household Information

Head of Household (required)

Number in Household (required)

Number of Adults (required)

Number of Children under 18 (required)

Living Arrangement (required)

Household Members (Include yourself) (Include name, relationship, date of birth, and age) (required)

Primary Insurance (required)

Do you have any convictions? (required)

Type of Conviction:

Release Date from Conviction:

SECTION D – Education Information

Highest Grade Completed (required)

Vocational Training/Bridge Program History (required)

SECTION E – Household Income Information

Income Sources (Check all that apply and include dollar amounts)

Include dollar amounts from household income information (ex: Employment Wages: $-----, Pension: $----, etc.)

Total Monthly Income: $

Annual Income For Past 12 Months, Your Earned Income (After taxes) (required)

Annual Income For Past 12 Months, Your Earned Income (Gross) (required)

In School / Training Program at time of completing intake form? (required)

SECTION F – Employment Information

Are you working at time of completing intake form? (required)

If you are currently employed, is this the longest you stayed at one job?

If not working, was your last job the job you held the longest?

In the last 12 months, number of months worked: (required)

Military Status (required)

SECTION G – General Release and Confidentiality Statement

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. Sometimes we are required to release some information from your file. We realize what you share is important, and you do have the right to ask us not to share information from your file. Please understand that this may affect our ability to enroll you in certain programs and /or provide a service(s). With that in mind, please review the statements below. Please review giving us your permission to release information.

• Crisis assistance – Discuss your bills, status of payments with utility companies, landlords, mortgage company/companies, etc.

• Landlord verification – Verify rent due, past due rent, late fees, etc.

• Employment and income verification – Verify your employment, your earnings, hours, and retention. Some programs can only enroll people who are below certain income levels.

• Aggregated data collection – Center participates in national demonstration projects that request the sharing of summary data on Urban League program clients. In these instances, your name or identifying information is not shared.

• Other:

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 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. Client Signature: (Required)

Date (Required)

Client Printed Name (Required)


Social Security Number (required)


Hide SSN

Birth Date (required)

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. Please check the box below that corresponds to your willingness to participate. I opt in: (required)