Program Registration Form

We are excited to meet you!
Please complete the form and submit. Once submitted within 48 hours you will be contacted by a LITE staff member to take about next steps.

The information gathered is used to identify resources to serve you and to help you achieve your goals. A LITE Leader will contact you within 48 hours of submission of this form.

We look forward to seeing you soon.

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Date

New registration

Name

First

Last

Phone

Address

Address Line 1

City

State

Zip Code

Please enter your birth date

Are you between the ages of 16 – 24?

How do you identify?

Female
Male
Non-binary
Prefers not to respond

Are you in school?

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

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 (Trades apprenticeship test preparation, coursework assistance)
Career Exploration (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)
Skills for Life (Earn while you Learn 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)
Skills for Life and Special programs (ex. Music matters program)

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?

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

All participants must Sign: I understand and agree to any policies, notices, and procedure regarding transportation provided by my organization and that I must arrive with and leave with the same transporter. At no time will I leave an event with an unauthorized person. I / my child will stay with the group while at the event and be at designated pick up and drop off locations at the assigned time. I understand and do not hold any representative of (LITE) responsible for accidents or injuries in the event an unforeseen incident occurs and that me / my child agree to abide by the rules set for transporting. In the event the rules are not abide by, LITE may refuse to allow me / my child from participating in future off-site events. LITE will only provide transportation for LITE clients that are registered and active in LITE programming, If you are not a registered and active LITE client you / your child must secure your own transportation. If offered I agree to the above and give permission for me/ my child to take the transportation offered to the above mentioned event

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.

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