• Proof of Identity – Youth Identity Access Program Intake Form

  Complete this form to access support for obtaining your identification documents and participate in the program.

• Participant Information

• Full Name*
  First NameMiddle NameLast Name
• Preferred Name
• Date of Birth*
   -Month -DayYear

  Date
• Age*
• Gender*
  Please Select Female Male Non-binary Prefer to self-describe Prefer not to say
• Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
• Email Address*
  example@example.com
• Home Address*
  Street Address

  Street Address Line 2

  CityState / ProvincePostal / Zip Code Please Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country
• City*
• State*
  Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
• ZIP Code*
• Emergency Contact Name*
  First NameMiddle NameLast Name
• Emergency Contact Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.

• Parent/Guardian Information

• Parent/Guardian Name*
  First NameLast Name
• Parent/Guardian Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
• Parent/Guardian Email*
  example@example.com
• Parent/Guardian Signature*

• Referral Information

• How did you hear about the program?*
  SchoolParent/GuardianFriendSocial MediaJuvenile Justice ReferralProbation OfficerCommunity OrganizationPark DistrictOther
• Referral Organization Name
• Referral Contact Person
  First NameMiddle NameLast Name
• Referral Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.

• Document Support Needed

• State ID*
  State IDDriver’s LicenseBirth CertificateSocial Security CardReplacement IDPermit PreparationAddress Verification HelpDMV Appointment AssistanceOther
• Please explain your current situation or what support you need.*

• Transportation & Participation

• I understand transportation may be provided for scheduled trips.*
  Yes
• I understand all participants are expected to behave respectfully during transportation and program activities.*
  Yes
• I understand completion of this form does not guarantee immediate document approval through outside agencies.*
  Yes

• Signatures

• Participant Signature*
• Date Signed*
   -Month -DayYear

  Date
• Parent/Guardian Signature
• SubmitSubmit
• Should be Empty: