Youth Transition Application

Participant Information

Preferred Name (If Applicable)

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

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)

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.)

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?

Consent and Signatures

Signature of Guardian/Participant (if 18+)

(Please Type Your Full Name)

Signature of Guardian/Participant (if 18+)

(Please Type Your Full Name)

Thank you for completing this application! If you have any questions, please contact us at:

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

Youth Transition Program

Participant Information

Emergency Contact Information

Medical and Support Needs

Behavioral and Emotional Support

Education and Skills Development

Accommodations and Accessibility Needs

Family/Guardian Input (Optional)

Consent and Signatures

Mission Statement

Compliance

View Bus Route

Address

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