Intake Form

Education Matters Southern Indiana

Education Matters Southern Indiana is a FREE service to help adults in five counties in Southern Indiana find their way back to and through college. Congratulations on taking your first steps today toward reconnecting to college! 

If you live in one of the following counties in Southern Indiana: 
  • Clark, 
  • Floyd, 
  • Harrison, 
  • Scott or
  • Washington 
we encourage you to submit the following registration form to continue your journey. 

Please fill out as many of the questions below as possible so that we can serve you better, faster, and more effectively. Remember: our services are always FREE.  We will NEVER sell or give away your information. 

This form may take you 5-10 minutes to complete, but it will allow us to immediately tailor advising services to you and other opportunities. After you submit the form, you will see a page with important information on next steps. 

Thank you, and we look forward to assisting you,
The Education Matters Southern Indiana Advising Team

Your email will be used to contact you for advising. You will also receive occasional newsletters, information about opportunities for Comebackers like you and requests to update your information in our records. You will always receive opt-out options for all.

Enter the number without spaces or dashes.

The following information is considered confidential by many people. We are concerned with your privacy as well. Please know that this information is used only in aggregate, for fund-raising purposes, so that we may continue to provided our services for free. We appreciate your support as you consider providing the requested information.


Please tell us a little about your educational experience.

By submitting this form I give permission to Education Matters Southern Indiana to forward my information to its partner institutions for purposes of assisting with my college admissions/enrollment.

I give permission to the Admissions/Office of Enrollment Management/Registrar of the College/University I shall be attending to release to Education Matters Southern Indiana verifying my enrollment status and my official transcript.

I fully understand that all information given on this application and information released to Education Matters Southern Indiana or its partner institutions is protected by the Federal Privacy Act and, therefore will be kept confidential. Education Matters Southern Indiana promises it will NEVER sell or give away personal information.

I certify that all information that I have provided on this application is accurate and true to the best of my knowledge and ability.

If you have questions now or later, please contact our advisors: or call 812-625-7501