2025 YLF Delegate Application

YLF 2025 Delegate Application

Applications due by Dec 20, 2024!
In order to complete to this application form, you will need the following information:

- Your home address - Know the name of your primary disability and other diagnosed disabilities (if applicable) from your teacher - Your parent/guardian(s) phone number and e-mail address - Your school/18-21 program's name, address, and phone number - Any employment experience; including employment site, job title, supervisor's name, and dates of employment - Information for 2 personal references; including their name, phone number, and e-mail address
Directions

Complete each question below. Please note the the questions with * are required. You may have whatever assistance you need to complete this form. You may dictate your answers to someone and they complete the form for you. Audio or video applications are accepted, provided all the information is included. If you cannot complete the form in one sitting, your information will be saved for up to 30 days as long as you return to this link (sent to you via e-mail) on the same device. In order to utilize the 'save' feature you will need to fill in your first and last name and e-mail address before selecting 'save'. Applications must be submitted no later than December 20, 2024 by 11:59p.m. Once you have completed your application please click 'submit.' You will receive a confirmation e-mail to indicate that your application has been submitted.
Student's Information
Student's Name*

First NameLast NamePreferred Name
Birth Date*

MonthDayYear
Current Age*
Gender (sex assigned at birth - information will be used for roommates and room selection)*

MaleFemale
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Cell Number
Please enter a valid phone number with area code.
Student's E-mail*
example@example.com
Primary Diagnosed Disability (please only select one)*

Autism Spectrum DisorderIntellectual Disability (Cognitive Impairment)Blind/Visually Impaired (I read Braille)Blind/Visually Impaired (I read LARGE print)Learning Disability (Reading, Math, Written Expression)Neuromuscular/Orthopedic (Physical Disability)Attention-Deficient/Hyperactive Disorder (ADHD)Traumatic Brain Injury (TBI)Deaf/Hard of Hearing (I use sign language to communicate)Deaf/Hard of HearingMental Health (Depression, Anxiety, Bipolar)Multiple DisabilitiesOther (if other please note below)
If you selected "Multiple Disabilities" above, please list your primary disability.
Other Diagnosed Disabilies

Autism Spectrum DisorderIntellectual Disability (Cognitive Impairment)Blind/Visually Impaired (I read Braille)Blind/Visually Impaired (I read LARGE print)Learning Disability (Reading, Math, Written Expression)Neuromuscular/Orthopedic (Physical Disability)Attention-Deficient/Hyperactive Disorder (ADHD)Traumatic Brain Injury (TBI)Deaf/Hard of Hearing (I use sign language to communicate)Deaf/Hard of HearingMental Health (Depression, Anxiety, Bipolar)Other (if other please note below)
In your own words, please describe how your disability affects you at home and at school.*
How did you hear about YLF?*

TeacherVR/SBVI CounselorParentFriendOther (if other please note below)
Parent/Legal Guardian Information
Mother/Guardian's Name*

First NameLast Name
Mother/Guardian's Cell Number*
Please enter a valid phone number with area code.
Mother/Guardian's E-mail
example@example.com
Father/Other Guardian's Name

First NameLast Name
Father/Other Guardian's Cell Number
Please enter a valid phone number with area code.
Father/Other Guardian's E-mail
example@example.com
Vocational Rehabiliation (VR) Information
Do you receive services from either the Division of Rehabilitation Services (also known as VR) or the Service to the Blind & Visually Impaired (also known as SBVI)?*

YesNoI don't know
If so, please write the name of your VR or SBVI Counselor
School Information
Grade in School*
Name of High School/18-21 Program*
If attending an 18-21 Program, please note your home school district below:
School's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Expected year of graduation or exiting from school*
High School Special Education Teacher's Name*
School, Community, and Employment Involvment
School and Community Involvement
Please list out the school, volunteer, religious, social, athletic, or other activities and/or organizations that you have participated in during high school. Please include the name of the activity and/or organization and the grades in which you participated in for each of them.

If you haven't participated in any activities/organizations please write N/A.
Activity/Organization #1*
Activity/Organization #2
Activity/Organization #3
Activity/Organization #4
Activity/Organization #5
Employment
Do you have a job?*

YesNo
If so, how many hours do you work per week?
Are you or have you been involved with Project Skills through VR or SBVI?*

YesNoI don't know
Please list out employment site, job title, supervisor's name, and dates worked for each of your employment experiences.
Employment #1 (if applicable)
Employment #2 (if applicable)
Employment #3 (if applicable)
Employment #4 (if applicable)
Short Answers
Tell us about yourself (some of your hobbies, interests, and about your family).*
Share with us an important experience you have had as a young person with a disability.*
What are three (3) things that concern you most about the future?*
Who do you look up to and why? (Tell us about a person who has positively influenced your life)*
References
Personal Reference #1 - School Reference*
Personal reference MUST BE over 21 and NOT be related to you. This reference must be someone from your school. Please write their full name, phone number, and e-mail address.
Personal Reference #2 - Community Reference*
Personal reference MUST BE over 21 and NOT be related to you. This reference must be someone from your community (employers make great references). Please write their full name, phone number, and e-mail address.
Should be Empty:

YLF 2025 Delegate Application

In order to complete to this application form, you will need the following information:

Directions

Student's Information