NLI Program Application

Before you begin this application...
Please make sure you have the following information ready:
- Your address
- Your contact information (phone #, email)
- Your parent/guardian’s name
- Your parent/guardian’s contact information (phone #, email)
- Your CPS ID number
Section 1: Basic information
Name*
First Last
Home/Current Address*
Street Address City State / Province / Region ZIP / Postal Code
If you do not know your zip code...
Please visit this website to find out. You will need to enter your address, city, and state.
YOUR primary phone number*
(not your parent's number unless you have no other way to be contacted)
Please re-enter your primary phone number to confirm*
Whose phone number is this?*
- Your cell phone number
- Your home number
- Your parent/guardian's number
Best email address at which to reach you*
Please re-enter your email address to confirm*
Whose email address is this?*
- Your personal email
- Your school email
- Your parent/guardian's email
When is your birthday?
Month*
Day*
Please enter a number from 1 to 31.
The day of the month (ie: 15th)
Year*
Do you live or attend school in one of the following neighborhood communities: New City (Back of the Yards), North Lawndale, or Gage Park?*
If you are not sure, please visit this website to see a map.

You can type your address or your school name into the search box and if your address or school's address falls within a colored part of the map, answer yes. If it falls in an area of the map that is not colored, answer no.
- Yes
- No
Which of the following neighborhood communities do you live or go to school in?*
Would you like to sign up for the Mikva newsletter and receive emails about future opportunities?
- Yes
- No
We're sorry...
Unfortunately, you cannot apply for NLI unless you live in one of the neighborhoods listed above.

If you are in high school, you can apply for Mikva's Citywide Youth Councils here.
We're sorry...
...but you must be between the ages of 12 and 15 and be in at least 7th grade to qualify for the NLI program.

If you are in high school, you can apply for Mikva's Citywide Youth Councils here.

if you feel you received this message in error, please email barbarac@mikvachallenge.org

Section 2: Emergency Contact Information
Parent / Guardian Name*
First Last
Relationship to you*
- Parent
- Grandparent
- Sibling
- Aunt / Uncle
Parent/Guardian preferred language if not English
Parent / Guardian's phone number*
Parent / Guardian email address

If your contact does not have an email address, please leave this blank

Section 4: School Information
What grade are you CURRENTLY in?*
- 6th
- 7th
- 8th
- 9th
Current High School*
If your school was not listed above, please list here:*
High School Graduation Year*
What school do you attend?*
If you go to a Chicago Public School, what is your CPS ID number?

Please note that all Charter Schools in Chicago are CPS schools. Please enter your School ID# in this field.

If you are unable to locate your CPS ID # please leave this field blank and email it to barbarac@mikvachallenge.org as soon as you locate it.

Section 5: Commitment
It is very important that you are able to participate fully in programming. Please read the statement below carefully and provide an honest answer.
Commitment to Neighborhood Leadership Initiative*
This program is a year-round commitment. During the school year, councils meet after school for 2 1/2 hours every week.

Do you have any conflicts with this schedule (ie extracurricular activities, other job, sports, vacation, etc)?
- Yes
- No
- Not sure
If you have a conflict, or are not sure if you do, please describe it here:*

Section 6: Short Responses
Please be as detailed as possible. Each response should be at least 2 sentences long.
What’s an issue in your school or community that you are passionate about and why? Please propose a possible solution to it.*
What skills/experiences/talents/interests do you feel you can you contribute to this program?*
What would you like to gain from this program or get better at?*

Section 7: Submit Application
Please click the submit button below. You will receive an email confirmation once you submit. A Mikva staff member will reach out to you regarding next steps.
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Comments
This field is for validation purposes and should be left unchanged.

Youth Program Interest Form

Step 1 of 8

Before you begin this application...

Section 1: Basic information

If you do not know your zip code...

When is your birthday?

We're sorry...

We're sorry...

Section 2: Emergency Contact Information

Section 3: Getting to know more about you

Section 4: School Information

Section 5: Commitment

Section 6: Short Responses

Section 7: Submit Application

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