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Save the date! STRIVE Rocks 2023, May 5th & 6th! Donate or Register here!

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STRIVE Membership Form

STRIVE Membership Form

Member's Name:
Preferred Nickname:
Preferred Pronouns:
Age:
Date of Birth:
Gender:
Email:
Phone #:
Address:
City/Town:
State:
ZIP:
Member Guardian Status:

Parent/Guardian

Name:
Address:
City/Town:
State:
ZIP:
Home Phone #:
Cell Phone #:
Work/Business Phone #:
Email:

Parent/Guardian

2. Name:
Address:
City/Town:
State:
ZIP:
Home Phone #:
Cell Phone #:
Work/Business Phone #:
Email:

Membership Information

Please complete the following section as thoroughly as possible. This information enables us to plan a safe and successful experience for the member

Disabilities

Please check any that apply and add any additional under “other”
Asthma:
ADD:
ADHD:
Aparaxia:
Art:
As:
Autism:
Bi Polar:
Blind:
Brain Injury:
Cerebral Palsy:
Deaf:
Diabetes:
Dual Diagnosis:
Down Syndrome:
Intellectual Disability:
OCD:
Paraplegic:
PDD:
Quadriplegic:
Scoliosis:
Seizure Disorder:
Spina Bifida:
OTHER:
Uses wheelchair:
Uses crutches:
Wears braces:
Uses walker:
Has allergies:
Has seizures:
Takes medication:
Wears collection bag:
Incontinence:
Has special diet:
Has catheter:
Loose stool:
Wears helmet:
Has shunt:
Chair repositioning:
Please describe in detail what assistance is needed in the areas noted above:
Communication: How does the member communicate? Please note any special signs or gestures if applicable?:
FOOD ALLERGIES: If the student has food allergies, please give us more information.:
Please list the food, reaction, and treatment as applicable

Behavioral Concerns:

Please describe any behavioral issues:
Any hospitalizations due to non - medical reasons?:
Does the student exhibit aggressive/confrontational behavior (i.e. bullying, antagonizing, name calling, etc.)?:

Photo Release:

Check if you agree to consent (leave unchecked if you disagree)
I DO consent to and authorize the use and reproduction by PSL Services/STRIVE of any and all photographs and any other audio/visual materials taken of participant for promotional materials, educational activities, exhibitions or for any use for the benefit of the program:
Signature:
Date:
I would like to recieve the PSL Services/STRIVE monthly newsletter:
Please contact me how I may help:
I am interested in fundraising (STRIVE Rocks, Annual Auction, etc.):

Transportation Alert:

(Alerts us to people you DO NOT want to pick up the student) As a parent or legal guardian, I DO NOT authorize my students to be released/picked up by thefollowing persons:
Name:
Relationship:
Name:
Relationship:
Signature:
Date:
*A STRIVE staff member will be in touch annually to update this STRIVE Membership form*