Youth Transition Application

After completing this Youth Transition Application, please take The Youth Transition pre-assessment. The assessment is an important way for our team to get to know you more as we consider your application.  Please complete the pre-assessment with as much detail as possible!

 

  • Programs of Interest





  • Contact Information











































  • Emergency Contacts













  • Educational Information



  • Nature of Disability

    Although we understand that it is your right not to disclose disabilities, this program is focused on supporting individuals with disabilities.
  • (allergies or other needs, such as seizure disorders)









  • Employment Information






















  • Additional Information














































  • RELEASE FORMS

  • Authorization for Treatment of Participant – Consent, Release and Covenant

    The undersigned parent/guardian represents to The Chicago Lighthouse that the minor named below is in his and/or her legal custody and control; that the undersigned desires said minor to participate in the programs of The Chicago Lighthouse; and that for purposes of said participation the undersigned agrees, authorizes and states as follows:

  • I (we) authorize The Chicago Lighthouse and its officers or staff employees as agent(s) for the undersigned
    to obtain and consent to any X-ray examination, anesthetic, medical, dental, surgical diagnosis, treatment and hospital
    care which is deemed advisable, and is to be rendered to said minor under general or specific supervision of any surgeon
    licensed under the provision of the Medical Practice Act or the medical staff of a licensed hospital or by a dentist licensed
    under the provisions of the Dental Practice Act, whether such diagnosis of treatment is rendered at the office of said
    physician or dentist or at the said hospital. I (we) also understand and agree that any and all such medical, dental, hospital or similar expenses incurred in the treatment of my (our) child will be borne by myself (ourselves). We understand that no representation of such coverage exists or is intended by this form.
    It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment or care being required but is given to provide authority and power on the part of The Chicago Lighthouse (as aforesaid) as my (our) agent(s), to give specific consent to any and all such diagnosis, treatment or care which a licensed physician or dentist in the exercise of his/her best judgment may deem available. This authorization shall remain effective while the minor is enrolled in any Chicago Lighthouse for People Who Are Blind or Visually Impaired program, unless sooner revoked in writing and delivered. The undersigned further releases The Chicago Lighthouse, and its officers, agents and employees, from any and all legal responsibility for accidents or sickness occurring during or related to the period of time said person is a participant in programs of The Chicago Lighthouse. I (we) further agree and covenant (for valuable consideration, receipt of which is acknowledged) that neither said person nor I (we) will institute any suit or action of damage, loss or injury of any kind, whether to person or property, whether to me (us), individually, or as parents/guardians relating to the programs or activities of The Chicago Lighthouse in which the minor participates.


    I hereby authorize and give permission for the participant’s name, photograph, video and/or other identifying information (such as age, eye condition, etc.) to be used by The Chicago Lighthouse for publicity, collaborative or training purposes. I understand such uses may include brochures, newsletters, website entries, press releases or written stories without payment or any other compensation. I further understand some uses may be for information and material sent to other organizations/companies (newspapers, television, radio, conference presentations, etc.) and that the materials will become the property of The Chicago Lighthouse and will not be returned.


    I hereby authorize and give permission to The Chicago Lighthouse to obtain and/or provide information to school district(s) , optometrist/ophthalmologist and/or Bureau Blind Services (BBS) for programming and collaboration regarding the participant listed below. The Chicago Lighthouse may contact participants to gather opinions about the programs attended.


    I hereby authorize and give permission for the participant identified below to participate in any off-site activities as a part of the selected programs. I understand such activities will be provided in a vehicle owned or rented by The Chicago Lighthouse and will be accompanied by a Chicago Lighthouse staff member.


    I hereby authorize and give permission to The Chicago Lighthouse to provide transportation for the participant identified below during Chicago Lighthouse programs for purposes of participating in programming and off- site activities.

  • MM slash DD slash YYYY

  • This field is for validation purposes and should be left unchanged.









For more information, please contact Marla Garstka at marla.garstka@chicagolighthouse.org | (312) 405-2699.

 

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