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IADL Packet · Ages 12–16

Independent Living Skills

IADL Packet Ages 12–16

Real-looking practice forms and guided reflection questions for the everyday real-world tasks middle and early high school students are beginning to encounter — filling out forms, reading labels, managing money, and navigating the adult world.

What's inside — 20 pages

Pages 2–3 — School or Club Application Form — filling out personal info, availability, references

Pages 4–5 — Doctor's Office Paperwork — health history, consent, insurance basics

Pages 6–7 — Reading a Restaurant Menu — Honest Abe's Lincoln, ordering, calculating cost and tip

Pages 8–9 — Prescription Label — reading directions, warnings, and refill information

Pages 10–11 — Understanding a Bank Account Statement — deposits, withdrawals, and fees

Pages 12–13 — Writing a Check — filling out every field correctly

Pages 14–15 — Utility Bill — understanding a phone bill, due dates, and overage charges

Pages 16–17 — Online Form Safety — usernames, passwords, and identifying safe vs unsafe sites

Pages 18–19 — Tip Calculation and Bill Splitting — math for real dining situations

Page 20 — Clinician Reference — goals, grading, and coaching notes

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IADL Packet · Ages 12–16 · School Application

Real-World Form Practice

Completing a School or Club Application

Fill out this practice application form completely. Use a pencil so you can erase and redo it. Read every question before you write — some questions have more than one part.

Lincoln Community Youth Programs

After-School & Summer Enrichment · Lincoln, NE 68508

Youth Volunteer & Leadership
Application Form

Personal Information

First Name

Last Name

Date of Birth

Age

Grade

Home Address

City, State, Zip

Phone Number

Email Address

Program Interest

Which programs are you interested in? Check all that apply.

After-School Tutoring

Community Garden

Youth Leadership Council

Sports & Recreation

Arts & Crafts

Technology Club

Availability

Check the days you are available after school (3:00–5:30 PM):

Monday

Tuesday

Wednesday

Thursday

Friday

Emergency Contact

Contact Name

Relationship to You

Contact Phone Number

Short Answer

Why do you want to join this program? (Write 1–2 sentences)

Applicant Signature

Date

By signing above, I confirm that all information provided is accurate and complete to the best of my knowledge.

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IADL Packet · Ages 12–16 · School Application

Reflection Questions

Thinking About the Application

Let's think about what you just filled out

What information did you need to know before you could fill out this form? Make a list of at least 4 things.

Why do you think programs ask for an emergency contact? Who would YOUR emergency contact be?

What does your signature mean on a form? Why is it important?

One section asked about your availability. What does 'availability' mean and why would an organization need to know this?

If you made a mistake on a paper form, what is the best way to fix it? (Hint: there are two acceptable ways.)

Real-World Connection

Applying This Skill

When will you use this?

Applications like this one appear when you sign up for after-school programs, sports teams, volunteer opportunities, summer camps, community organizations, and eventually — jobs. The fields are almost always the same: personal information, contact details, availability, and a short answer or two.

Tips for real applications

Read the whole form before you write anything
Print neatly — messy handwriting creates a bad first impression
Never leave a field blank — write "N/A" if something doesn't apply
Double-check your phone number and email — a wrong digit means they can't reach you
Ask an adult to review before you submit

Challenge question

If you were applying to volunteer at Lincoln Children's Museum and they asked you to describe a time you helped someone — what would you write? Draft your answer below in 2–3 sentences.

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IADL Packet · Ages 12–16 · Medical Paperwork

Real-World Form Practice

Completing Doctor's Office Paperwork

This is a shortened version of the kind of new patient form you fill out at a doctor's office. Fill it out using either real or made-up information for practice.

Midwest Family Health Clinic

4821 O Street · Lincoln, NE 68510 · (402) 555-0192

New Patient Health History
Please print clearly in ink

Patient Information

Patient First Name

Last Name

Date of Birth

Sex at Birth

Phone

Today's Date

Address

Reason for today's visit

Health History

Do you have or have you ever had any of the following? Check YES or NO for each.

Asthma

Yes

No

Diabetes

Yes

No

Heart condition

Yes

No

Allergies

Yes

No

Epilepsy / seizures

Yes

No

Anxiety or depression

Yes

No

ADHD

Yes

No

Broken bones (fractures)

Yes

No

Surgery

Yes

No

Hospitalisation

Yes

No

Allergies & Medications

List any allergies (food, medication, environmental)

List any medications you currently take (include vitamins/supplements)

Insurance

Insurance Provider

Member ID Number

Policy Holder Name

Relationship to Patient

Patient or Guardian Signature

Date

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IADL Packet · Ages 12–16 · Medical Paperwork

Reflection Questions

Thinking About Medical Paperwork

Understanding what you filled out

What is a 'policy holder'? If you are on your parent's insurance, who is the policy holder?

Why do doctors need to know what medications you are taking, even vitamins and supplements?

The form asks about your health history. Why would a new doctor need to know about things that happened to you years ago?

What does it mean to give your 'informed consent' by signing a medical form?

What would you do if you weren't sure whether something on the health history list applied to you?

Things to know before a doctor's appointment

Your date of birth — you will be asked many times
Your insurance card — or your parent's card if you are on their plan
A list of any medications you take and the doses
Any known allergies
The names of other doctors you see regularly

Privacy at the doctor

Your medical information is private and protected by law (HIPAA). Doctors and their staff cannot share your information with others without your permission — with some exceptions for safety. As you get older, you may have the right to make your own medical decisions and to ask for confidentiality on certain topics.

Challenge question

Imagine you are at the doctor alone for the first time (no parent). The doctor asks you if you have any allergies and what medications you take. Do you know that information right now? Write down what you would say — and identify anything you would need to find out before your appointment.

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IADL Packet · Ages 12–16 · Restaurant Menu

Real-World Form Practice

Reading a Restaurant Menu

Use this real menu from Honest Abe's Burgers & Freedom in Lincoln to answer the questions on the next page. Read the full menu before you start.

Classic Burgers

Fries & Sides

Rotating Burgers

Ask your server about today's rotating specials — we change them regularly!

Handcrafted Shakes

Drinks

Nebraska sales tax: 7%
Gratuity not included. We suggest 15–20% for dine-in service.
Gluten-free bun available (+$1.50) · Vegan patty available (+$1.00)

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IADL Packet · Ages 12–16 · Restaurant Menu

Reflection & Math Practice

Using the Menu

Ordering practice

You are eating at Honest Abe's with a friend. You have $35.00 total to spend (including tax and tip). Fill in your order:

Your burger

Your side

Your drink

Your friend's order

Food subtotal:$

Tax (7%):$

Tip (18%):$

Grand Total:$

Math practice — tip calculation

Use these shortcuts to calculate tip quickly:

10% tip: Move the decimal one place left
$24.50 → $2.45
15% tip: Find 10%, then add half
$24.50 → $2.45 + $1.23 = $3.68
20% tip: Find 10%, then double it
$24.50 → $2.45 × 2 = $4.90

Your bill is $18.75. Calculate:

10% tip

15% tip

20% tip

Reflection questions

What does 'gratuity not included' mean on the menu? Who is gratuity for and why do we pay it?

The menu says Nebraska sales tax is 7%. What does sales tax pay for?

If you only had $20 and needed to eat lunch — what would you order and how much change would you get back? (Don't forget tax!)

What would you ask the server if you had a food allergy that wasn't mentioned on the menu?

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IADL Packet · Ages 12–16 · Prescription Label

Real-World Form Practice

Reading a Prescription Label

Read this practice prescription label carefully. All information on this label matters — some of it is safety-critical. Answer the questions on the next page.

Walgreens Pharmacy

(402) 555-0144 · 4850 O Street, Lincoln NE

Lic. #NE2847301

Prescription #:RX-7734821

Date Filled:06/10/2025

Prescribing Doctor:Dr. Sarah M. Jensen, MD

Patient Name:Jordan A. Martinez

Date of Birth:03/14/2010

Amoxicillin 500 mg Capsules

Qty: 30 capsules · Generic for: Amoxil

DIRECTIONS: Take ONE (1) capsule by mouth THREE (3) times daily for 10 days. Take with food or milk. Complete the full course of treatment even if you feel better.

Refills remaining:0 (No refills)

Discard after:12/10/2025

⚠ KEEP OUT OF REACH OF CHILDREN
⚠ May cause stomach upset. Take with food.
⚠ Finish all medication as directed by your doctor.
⚠ May cause allergic reaction. Stop use and seek medical attention if rash, hives, or difficulty breathing occurs.
⚠ Do not share this medication with others.

Key parts of any prescription label

Drug name and strength — what you are taking and how much
Directions — exactly how and when to take it
Refills — how many times you can get more without a new prescription
Discard after — do not take after this date
Prescribing doctor — who ordered this medication
Warnings — important safety information to read

Safety rules for medication

Never take someone else's prescription
Never share your prescription with anyone else
Always finish antibiotics — stopping early creates resistant bacteria
Store medications as directed — some need refrigeration
Dispose of unused medication safely — many pharmacies have drop boxes

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IADL Packet · Ages 12–16 · Prescription Label

Reflection Questions

Understanding the Prescription

Use the label on the previous page to answer these questions

According to the directions, how many capsules would Jordan take in one full day? How many total capsules for the whole 10-day course?

The label says '0 refills remaining.' What does this mean? What would Jordan need to do if they needed more medication?

The label says 'discard after 12/10/2025.' It is now July 2025. Is this medication still safe to use? How much time is left?

What should Jordan do if they develop a rash after taking this medication?

The label says to 'complete the full course of treatment even if you feel better.' Why do you think this instruction is important?

Dose schedule

Jordan needs to take this medicine 3 times per day. Plan a schedule for a typical school day. Write what times would work best and why:

Morning dose — time and situation

Afternoon dose — time and situation

Evening dose — time and situation

Thinking ahead

As you get older you will likely manage your own medications. What strategies could help you remember to take medicine on time?

Strategy 1

Strategy 2

Strategy 3

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IADL Packet · Ages 12–16 · Bank Statement

Real-World Form Practice

Reading a Bank Account Statement

This is a practice bank statement for a student savings account. Read all the transactions carefully — the balance changes with every entry.

First Nebraska Community Bank

Youth Savings Account · Statement Period: June 1–30, 2025

Account Holder: Alex J. Thompson

Account #: ****4821

Routing #: 104900014

Opening Balance

$247.50

Total Deposits

+$185.00

Total Withdrawals

-$143.25

Closing Balance

$289.25

Date	Description	Deposits (+)	Withdrawals (−)	Balance
06/01	Opening Balance	—	—	$247.50
06/03	Direct Deposit — Lawn Care (Johnson family)	+$45.00	—	$292.50
06/05	Debit Card Purchase — Target Lincoln	—	-$23.47	$269.03
06/08	ATM Withdrawal — 14th & O St	—	-$40.00	$229.03
06/08	ATM Fee (out-of-network)	—	-$3.00	$226.03
06/12	Mobile Deposit — Birthday gift from grandparents	+$50.00	—	$276.03
06/15	Debit Card Purchase — Honest Abe's Burgers	—	-$17.28	$258.75
06/18	Direct Deposit — Lawn Care (Peterson family)	+$45.00	—	$303.75
06/22	Debit Card Purchase — GameStop Lincoln	—	-$34.50	$269.25
06/25	Debit Card Purchase — Walgreens	—	-$12.00	$257.25
06/28	Direct Deposit — Lawn Care (Johnson family)	+$45.00	—	$302.25
06/30	Monthly Maintenance Fee	—	-$13.00	$289.25
END OF STATEMENT — June 30, 2025		+$185.00	-$143.25	$289.25

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IADL Packet · Ages 12–16 · Bank Statement

Reflection Questions

Understanding the Bank Statement

Use the statement on the previous page to answer these

On June 8th, there are TWO separate transactions — an ATM withdrawal and an ATM fee. What is an out-of-network ATM fee and how could Alex have avoided it?

Alex earns money doing lawn care. Looking at the statement, how much did Alex earn from lawn care in June? Is this a job or a business?

The statement shows a 'Monthly Maintenance Fee' of $13.00. What do you think this fee is for? Is this a good deal or not? Explain.

If Alex wants to buy a used bike for $175 next month, will they have enough? What would Alex need to plan?

Look at Alex's spending in June. Which purchase do you think was the best use of money? Which might Alex want to reconsider?

Key bank account vocabulary

Deposit: Money going INTO your account

Withdrawal: Money going OUT of your account

Balance: The total amount currently in your account

Direct Deposit: Money transferred electronically, often from a job

Debit Card: A card that spends money directly from your account

Routing Number: A 9-digit number that identifies your bank

Account Number: YOUR specific account at that bank

Maintenance Fee: A monthly charge the bank takes for keeping your account open

ATM Fee: A charge for using an ATM that doesn't belong to your bank

Mobile Deposit: Depositing a check by photographing it with your phone

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IADL Packet · Ages 12–16 · Writing a Check

Real-World Form Practice

Writing a Check

Checks are used less often than they used to be, but knowing how to write one correctly is still an important adult skill — for rent, utilities, and formal payments. Fill out both practice checks below.

Label each part of a check:

Alex J. Thompson

1842 Vine Street, Lincoln NE 68508

CHECK NO.

1042

Date:

Pay to the order of:

$

DOLLARS

First Nebraska Community Bank · Lincoln, NE

⑆104900014⑆ ⑈00004821⑈ 1042

Memo:

Signature:

Practice scenario — fill out the check above:

Today is July 15, 2025. You owe your neighbor, Mrs. Karen Hoffman, $42.50 for babysitting last weekend. Write her a check from Alex's account. In the memo line, write what the payment is for. Then sign it.

How to write the dollar amount in words

The long line on the check requires the amount in words. This prevents people from changing the number.

$42.50 → Forty-two and 50/100 dollars
$127.00 → One hundred twenty-seven and 00/100 dollars
$8.75 → Eight and 75/100 dollars

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IADL Packet · Ages 12–16 · Writing a Check

Reflection Questions

Understanding Checks

Questions about checks and payment

What is the difference between the routing number and the account number on a check?

Why do checks require you to write the amount twice — once in numbers and once in words?

What is the memo line for? Is it required? Why might it be useful?

If you write a check and there is not enough money in your account, what happens? What is this called?

Checks are used less often today. What payment methods have replaced them for most everyday purchases?

Write these amounts in words — check practice

$67.00 in words:

$13.25 in words:

$250.00 in words:

$9.75 in words:

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IADL Packet · Ages 12–16 · Utility Bill

Real-World Form Practice

Reading a Phone Bill

Read this practice phone bill carefully. Every section contains information you need to pay correctly and avoid extra charges.

Great Plains Wireless

Account Summary · Billing Period: June 1–30, 2025

Account #: GP-44821-NE
Due Date: July 18, 2025

Account Holder

Jordan A. Martinez

Phone Number

(402) 555-7821

Plan

Student 5GB Data Plan

Charges This Month

Monthly Plan — Student 5GB Data	$35.00
Taxes & Regulatory Fees	$4.22
Government Surcharge	$1.15
Previous Balance (May)	$0.00
Late Payment Fee	$0.00
TOTAL AMOUNT DUE	$40.37

Data Usage This Month

Plan Allowance

5.00 GB

Data Used

4.72 GB

Data Remaining

0.28 GB

⚠ Warning: You have used 94% of your monthly data. If you exceed your plan limit, additional data is charged at $15.00 per GB. Consider connecting to Wi-Fi to avoid overage charges.

Payment Methods

Pay online at greatplainswireless.com · Auto-pay available (save $5/mo) · By phone: (800) 555-4400 · By mail: PO Box 1200, Lincoln NE 68501 · Note: Late payments after July 18 will incur a $10 late fee.

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IADL Packet · Ages 12–16 · Utility Bill

Reflection Questions

Understanding the Phone Bill

Use the bill on the previous page to answer these

How much is the total bill? What date is it due? What happens if it is paid late?

Jordan has used 4.72 GB of their 5 GB data plan. They still have 8 days left in the month. What should Jordan do to avoid overage charges — and what specifically would help?

If Jordan goes over their data limit by 1.5 GB, how much extra would they be charged? What would the total bill be?

What is 'auto-pay' and what is the benefit of setting it up? Can you think of any risk or downside?

The bill includes taxes and regulatory fees. These were NOT part of the advertised $35 plan price. What does this tell you about reading the fine print when signing up for a plan?

Data saving strategies

Jordan is almost out of data. Which of these would help the most?

Connect to home Wi-Fi for streaming

Turn off background app refresh

Download videos and music at home before leaving

Stop using apps for the rest of the month

Upgrade to a bigger plan for next month

Monthly budget planning

Imagine you are responsible for your own phone bill. Fill in a simple monthly budget to see if you could afford it.

Monthly income (job, allowance, etc.)

Phone bill ($40.37)

Other expenses (food, activities, etc.)

Money left over after all expenses

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IADL Packet · Ages 12–16 · Online Form Safety

Real-World Skills

Staying Safe with Online Forms and Accounts

Every day you are asked to create accounts, enter passwords, and submit information online. Learning to do this safely is one of the most important skills of independent adult life.

✓ Signs a website is SAFE

URL starts with https:// (the 's' means secure)
A padlock icon appears in the browser bar
The web address looks correct — no typos or extra words
No urgent warnings that you need to act immediately
Contact information is easy to find
Privacy policy and terms of service are available

⚠ Red flags — UNSAFE website

URL starts with http:// (no 's' — not encrypted)
Urgent pop-ups saying you have won something
Requests for your Social Security number unexpectedly
Requests for payment via gift card
Poor spelling or grammar throughout the site
No physical address or contact information

Password Safety — Practice Activity

Rate each password below: Weak, Medium, or Strong — then explain why.

Password	Rating	Why?
password
Jordan2010!
Tr$7kL@9mP#2
abc123
NebraskaHawks#2025
qwerty

Information that is ALWAYS private — never share online

❌ Social Security Number

❌ Full bank account numbers

❌ Passwords

❌ Home address (to strangers)

❌ Credit card numbers

❌ Date of birth + full name together

❌ Your school or daily schedule

❌ Photos of financial documents

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IADL Packet · Ages 12–16 · Online Form Safety

Reflection Questions

Thinking About Online Safety

Real-world scenarios — what would you do?

You receive an email that says 'Congratulations! You have won a $500 gift card. Click here to claim your prize and enter your bank account number to receive funds.' What are the red flags? What should you do?

You want to create an account on a new gaming website. The site asks for your full name, date of birth, home address, and phone number. Which of these would you provide and which would you leave out or change? Why?

What makes a password strong? Create a strong password for a practice school account and explain why it is secure. (Do not use a real password you actually use.)

What should you do if you accidentally enter your personal information on a website that turns out to be unsafe?

Creating a safe online account — checklist

Next time you create a new account online, use this checklist:

I checked that the website URL starts with https://

I verified the website is legitimate (searched for reviews or asked a trusted adult)

I used a strong password (mix of letters, numbers, symbols — at least 12 characters)

I did NOT use the same password I use for other accounts

I did NOT enter my Social Security number or full bank details

I read what the site will do with my information (privacy policy summary)

I have a way to remember this password safely (password manager or a secure private note)

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IADL Packet · Ages 12–16 · Tip & Bill Splitting

Real-World Math Practice

Tip Calculation and Bill Splitting

Use what you know about Honest Abe's menu to solve these real-world math problems. Show your work in the space provided.

Scenario 1 — Solo lunch

You order a Greatest Burger Ever ($12.95), Parmesan Truffle Fries ($4.95), and a fountain drink ($2.50). Nebraska sales tax is 7%.

Subtotal (food + drink)

Tax (7%)

15% tip on subtotal

Grand total

You pay with a $30 bill — change?

Scenario 2 — Splitting a bill

Four friends each order a $12.95 burger, Freedom Fries ($3.50), and a shake ($4.95). They want to split the total bill (after tax) equally and leave a 20% tip on the pre-tax total.

Total food cost (4 people)

Tax (7%)

20% tip (on pre-tax total)

Grand total

Each person's share

Scenario 3 — When the service was just okay

Your bill at Honest Abe's is $28.40 before tax. The service was slow but the food was great. You decide to leave a 12% tip instead of the usual 18-20%. How much is the tip and what is the total?

Subtotal

12% tip

Grand total with tax (7%)

Reflection questions about tipping

Why do we tip at restaurants? Who specifically does the tip go to?

Is tipping required? What would happen if nobody tipped at all?

Some apps and delivery services automatically add a suggested tip of 20-25%. Is this the same as a restaurant tip? Should you always accept the suggested amount?

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IADL Packet · Ages 12–16 · Clinician Reference

For the OT

Clinician Reference — Ages 12–16 IADL Packet

Goal bank

Sample Goals — Ages 12–16

STG — Form Completion

Student will independently complete a multi-section paper application form including personal information, availability, and a short-answer response, with no more than 2 prompts for missing fields, in 3 of 4 trials.

STG — Medical Paperwork

Student will accurately complete a new patient health history form by correctly identifying relevant personal health information and demonstrating understanding of insurance terminology, in 3 of 4 trials with no more than 2 verbal cues.

STG — Financial Literacy

Student will read a bank account statement and correctly identify the account balance, one deposit, one withdrawal, and one fee, and explain what each represents, in 3 of 4 opportunities.

STG — Prescription Reading

Student will read a prescription label and accurately identify the drug name, dose, directions, refill status, and two safety warnings, with no more than 1 verbal cue, in 3 of 4 trials.

LTG — Community Participation

Student will independently complete real-world application forms (school, job, community) using correct personal information, legible handwriting, and all required fields, with no adult support, in 4 of 5 observed opportunities.

Grading

How to Grade These Activities

Grade down (easier)

Pre-fill some fields to reduce reading demand
Provide a word bank for the bank statement vocabulary
Complete the math scaffolding before tip calculation
Allow use of calculator for math sections
Read instructions aloud

Grade up (harder)

Complete forms without any adult present
Role play the full doctor's appointment, not just the form
Add a second bank statement month and compare spending
Research actual Lincoln restaurants and build a budget meal
Have student create their own "safe password" system

Coaching notes

What to Emphasise With This Age Group

Students ages 12–16 are beginning to encounter real versions of these forms — school applications, sports sign-ups, and eventually first jobs. The goal is not perfection but familiarity. Students who have filled out a practice form are significantly less anxious when encountering the real version. Emphasise the pattern: every form has the same basic structure — who you are, how to reach you, what you need, and your signature confirming everything is true.

Financial literacy at this age is about understanding the concept — not mastering budgeting. The most important takeaway is that every transaction has a consequence, that fees are real costs, and that money decisions compound over time.

Inspire Pediatric Therapy

Lincoln & Omaha, Nebraska · inspirepeds.org · 402-413-7999

These resources are for educational and therapeutic purposes.
They do not constitute financial or legal advice.

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