Program Registration Form

Date *

Name *

First

Last

Phone *

Address *

Address Line 1

City

State

Zip Code

Email

Please enter your birth date

Are you between the ages of 16 - 24?

Yes
No

How do you identify? *

Female
Male
Non-binary
Prefers not to respond

Please select race and ethnicity *

Are you in school? *

Yes
No

If you are in school, what is the name of your school? (if not in school write NA)

If not in school, what is the highest grade you completed? *

Please provide a brief statement about your situation, what do you want to achieve by participating in LITE service?.

Identify the service that would best help you.

Academic Support (GED preparation, Trades apprenticeship test preparation, coursework assistance)
Career Exploration (Earn while you learn about careers and how to host a webinar, interview professionals and share with your peers)
Work Experience (Earn while you learn the skills needed by employers, demonstrate skills while you work, learn how to connect your skills with interviewing and resume building)
Positive Recreational Activity (Participate in arts, dance, and recreational activities as you learn how to manage positive social relationships, earn points toward activities)
Life Skills (Attend sessions where you learn money management, learn about housing, preparing for employment, or how to enroll in college courses.
Employment (career readiness, resume building, part time job placement, or full time job placement)

Choose the services that help you discovery your pathway to higher earning potential and adulthood.

What is your current employment status? *

Working part time
Working full time
Looking for work
Not looking for work

If you are working now, is this your first job? (if YES, please write yes in the box, If not please list your last 3 jobs and how long you worked at that job)

Do you know what your dream job looks like?

Yes
No
Somewhat

Do you have transportation?

Yes
No

Parent or other significant adult Name *

First

Last

What language to you feel most comfortable speaking?

Primary language spoken by parents/other significant adults.

Parent or other significant adult Phone

Parent or other significant adult Email

Is there any additional information for us to know in order to help you achieve your goals?

Consent for Promotional Purposes - permission to Leaders In Transformational Education (LITE) to use artwork, writing or pictures/videos taken at this event for the promotional purposes. I understand that refusal to sign this release will not affect delivery of service in any way. I am 18 years old or older/ I am a parent or guardian of a child under 18 years of age *

Yes
No

I/my child does not have a medical condition that I am aware of that prevents me / my child from participating in this activity. I agree to hold Leaders In Transformational Education (LITE) and any of its officers, employees, or volunteers free from any and all liability and waive all claims of damages or recompense for any accident, injury or disability to me or my property arising out of or connected with my participation in this activity/outing. I also authorize the Chief Executive Officer of (LITE), or duly designated representative, to secure the necessary medical, hospital and surgical attention, in the event of illness or physical injury to me/ my child during participation in this activity. By providing your signature below you have read and agree to the statement above. *

How did you hear about LITE?

Thank you for visiting our website. If you are not between the ages of 16 - 24, please check out the websites below for employment assistance.

(Village of Maywood) https://www.unemploymentofficelocations.net/maywood-workforce-center-unemployment-office-ol2203
(Austin community) http://www.habilitative.org
(City of Aurora) https://ides.illinois.gov
(City of Aurora) https://www.countyofkane.org/WDD/Pages/Default.aspx
Looking for some other assistance?

If you are looking of other assistance than what is listed above, submit your form and we will try to assist you.