Youth Transition Application

Youth Transition Program

Participant Information

Full Name
Date of Birth

Emergency Contact Information

Add Another Emergency Contact

Medical and Support Needs

Will medications need to be taken during program hours?
(e.g., wheelchair, hearing aids, communication devices, etc...)
(Triggers such as loud noise, bright lights, etc. and strategies that help)

Behavioral and Emotional Support

(e.g., visual schedules, breaks, quiet spaces, fidget tools, etc.)
Does the participant require any additional supervision?

Education and Skills Development

(e.g., life skills, communication, budgeting, social skills, etc.)
(Short and long-term goals encouraged)
(What are their hobbies, talents, or things they enjoy?)

Accommodations and Accessibility Needs

(e.g., visual aids, physical accessibility, assistive technology)
(e.g., visual, hands-on, verbal instruction)

Family/Guardian Input (Optional)

Preferred Method of Communication

Consent and Signatures

Permission to Participate in Program Activities
(Please Type Your Full Name)
Medical Treatment Authorization
(Please Type Your Full Name)
Media Release (Optional)
Thank you for completing this application! If you have any questions, please contact us at:

Phone: 316-942-6300
Email: info@ilrcks.org