STRIVE Membership Form

STRIVE Membership Form

Become a Member Today

STRIVE Membership Form

Member's Name:
Preferred Nickname:
Gender:
Preferred Pronouns:
Date of Birth:
Age:
Address:
City, State, Zip Code:
Member's Phone Number:
Member's Email Address:
Member Guardian Status:
Parent/Guardian 1 Name:
Guardian 1 Phone Number:
Guardian 1 Address (if different from applicant):
Guardian 1 Email:
Parent/Guardian 2 Name:
Guardian 2 Phone Number:
Guardian 2 Address (if different from applicant):
Guardian 2 Email:

If Parent/Guardian information is blank, please add an emergency contact below

Emergency Contact Name:
Emergency Contact Phone Number:

Member Information

Please complete the following section as thoroughly as possible. This information enables us to pla a safe and successful experience for the member.
Disabilities (please check any that apply and add additional in the space below if needed):
Other (please note):
Please check any that apply:
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:
Allergies: If the member has allergies, please give us more information (include allergy, reaction and treatment):
Behavioral Concerns Please describe any behavioral issues::
Does the member exhibit aggressive/confrontational behavior (i.e. bullying, antagonizing, name calling, etc.)? If so, please explain:
Any hospitalizations due to non-medical reasons? If so, please explain:

PHOTO RELEASE

I DO consent to and authorize the use and reproduction by PSL Services / STRIVE of any and all photographs and any other audio/visual material taken of participant for promotional materials, educational activities, exhibitions or for any use for the benefit of the program:
Signature Participant if over 18, or legal guardian:
Signature Date:
Print name of participant/legal guardian:

Transportation Alert

This alerts us to people you DO NOT want to pick the member. As a parent or legal guardian, I DO NOT authorize this member to be release/picked up by the following persons (please include name and relationship):
Signature Date:
Signature - participant if over 18, or legal guardian: