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About
About Us
Leadership Team
Career Opportunities
Current Openings
Job Inquiry Form
Information for Current Employees
Programs
All Programs
Social Programs
Camp STRIVE
Tweens
STRIVE Night
STRIVE 25
Post Secondary Education
STRIVE WorldWIDE
STRIVE U
STRIVE Bayside
Community Support
Community Support Programs
ACTIVE/WAVES
STRIVE Bayside
STRIVE Studios
Independent Living Skills
Home Support
STRIVE Bayside
Community Support
Wednesday Night Educational Series
STRIVE U
STRIVE Studios
STRIVE WorldWIDE
Educational Programs
STRIVE U
STRIVE WorldWIDE
TOPS
Wednesday Night Educational Series
Case Management
Mental Health Services
Events
STRIVE Events
Auction
3 Points for STRIVE
STRIVE Rocks!
STRIVE for FIVE
Kevin on the Roof
Support
Support STRIVE
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Donate
Buy Our Merchandise
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What Are My Rights?
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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*