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316-942-6300
3033 West 2nd St N. Wichita, KS 67203
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About
Board Of Directors
ILRC Staff
Job Application
Testimonials
Contact Us
What We Do
Core Services
Information & Referral (I&R)
Peer Support
Advocacy
Independent Living Services
Transition
Classes & Activities
Our Programs
Autism Program
The Difference
How It Works
Program Levels
Our Staff
Success Stories
Apply Now
Program FAQs
Youth Transition Program
Youth Transition Application
MERN
Dental Flex Funding
FMS/Payroll
FMS Payroll FAQs
Contact FMS/Payroll
Fundraisers & Events
Holiday Cards
ILRC Golf Tournament
Donate
Calendar
Arts & Crafts Class
Budgeting Class
Cooking Class
Fitness Class
Parent 2 Parent
Peer Support
WDRA Meetings
Resources
Bus Routes / Transportation
FAQ
ILRC News
Presentation Request
Provider Map
Public Housing Assistance
SILCK
Contact Us
316-942-6300
3033 West 2nd St N. Wichita, KS 67203
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Youth Transition Application
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Youth Transition Program
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Youth Transition Application
Youth Transition Program
Participant Information
Full Name
First
Last
Preferred Name (If Applicable)
Date of Birth
Month
Day
Year
Gender Identity/Pronouns (Optional)
Home Address (City, State, ZIP)
Phone
Email (Participant or Guardian)
Emergency Contact Information
Primary Emergency Contact Name
Relationship To Participant
Phone
Email
Add Another Emergency Contact
Yes
Secondary Emergency Contact Name
Relationship To Participant
Phone
Email
Medical and Support Needs
Primary Diagnosis or Areas Needing Support
Allergies (food, environmental, medications)
Current Medications (If Applicable)
Will medications need to be taken during program hours?
Yes
No
Assistive Devices or Technology Used
(e.g., wheelchair, hearing aids, communication devices, etc...)
Sensory Considerations
(Triggers such as loud noise, bright lights, etc. and strategies that help)
Dietary Restrictions or Preferences
Behavioral and Emotional Support
Does the participant have any specific behavioral or emotional support needs?
What strategies or tools help the participant stay comfortable and engaged?
(e.g., visual schedules, breaks, quiet spaces, fidget tools, etc.)
Does the participant require any additional supervision?
Yes
No
Please Explain
Education and Skills Development
Current School/Program (If Applicable)
Grade/Education Level
Skills the participant is working on or needs support with:
(e.g., life skills, communication, budgeting, social skills, etc.)
Participant goals for this program:
(Short and long-term goals encouraged)
Strengths and Interests
(What are their hobbies, talents, or things they enjoy?)
Accommodations and Accessibility Needs
Does the participant need specific accommodations to succeed in the program?
(e.g., visual aids, physical accessibility, assistive technology)
Preferred Learning Methods
(e.g., visual, hands-on, verbal instruction)
Family/Guardian Input (Optional)
Is there any additional information about the participant that would help us support them better?
Preferred Method of Communication
Email
Phone
In-Person Meeting
Consent and Signatures
Permission to Participate in Program Activities
I give permission for the participant to engage in all program activities.
Signature of Guardian/Participant (if 18+)
(Please Type Your Full Name)
Medical Treatment Authorization
I authorize program staff to seek emergency medical treatment for the participant if needed.
Signature of Guardian/Participant (if 18+)
(Please Type Your Full Name)
Media Release (Optional)
Do you consent to photos/videos of the participant being used for program promotion?
Thank you for completing this application! If you have any questions, please contact us at:
Phone: 316-942-6300
Email: info@ilrcks.org
