Youth ILS Application

Please provide the most information that you accurately can. This information will benefit you and your progress throughout your time with this program. Please inform the Program Director of any mistakes or changes that need to be made.
Date *
Date
Desired Program *
Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Gender *
Living Situation *
Guardian Information
Guardian Address
Guardian Address
Emergency Contact Information
Emergency Contact Address *
Emergency Contact Address
Emergency Contact 2 Information
Emergency Contact 2 Address
Emergency Contact 2 Address
Social Worker Information
Social Worker Address *
Social Worker Address
Funding *
Doctor Information
Clinic Address *
Clinic Address
(if different from Physician phone)
Health Information
Date of last clinic visit *
Date of last clinic visit
Hearing *
Vision *
Ambulation *
Toileting *
Personal Hygiene *
Diabetic *
Insulin Dependent *
Is there anything else you'd like to tell us about your child?
Signature (Parent or Guardian if child is under 18) *
Signature (Parent or Guardian if child is under 18)
By entering my name below, I verify that all of the information provided is correct to the best of my knowledge.