Contact Information Student's Name Preferred Nickname if Applicable Gender Male Female Date of Birth Email Phone # Address Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Guardian Status Self Parent Other If other selected, please type below Emergency Contacts Mother/Guardian's Name Mother/Guardian's Address (if different from applicant) Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Mother/Guardian's Home Phone Mother/Guardian's Employer Mother/Guardian's Work Phone Mother/Guardian's Cell Phone Mother/Guardian's Email Father/Guardian's Name Father/Guardian's Address (if different from applicant) Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Father/Guardian's Home Phone Father/Guardian's Employer Father/Guardian's Work Phone Father/Guardian's Cell Phone Father/Guardian's Email Please select the program you would like to attend Full time: (Monday-Friday: 9am-5pm) $225 per week Part time: (3 days a week 9am-5pm) $150 per week Early Drop off: 8 - 9am for $9 per day Payments may be made at the beginning of each week or eachmonth. PSL Services/STRIVE accepts personal checks, as well as MasterCard, Visa, and Discover. Please check off the days and times you would like to attend: Monday 9:00am-5:00pm 9:00am-1:00pm 1:00pm-5:00pm Tuesday 9:00am-5:00pm 9:00am-1:00pm 1:00pm-5:00pm Wednesday 9:00am-5:00pm 9:00am-1:00pm 1:00pm-5:00pm Thursday 9:00am-5:00pm 9:00am-1:00pm 1:00pm-5:00pm Friday 9:00am-5:00pm 9:00am-1:00pm 1:00pm-5:00pm Does student have a case manager? Yes No If yes, please fill out the following information about this case manager: Name, Organization, Email, Phone # Name Organization Email Phone # Student Information Please complete the following section as thoroughly as possible. This information will enable us to plan a safe and successful experience for the students. Please check all that apply. ADD ADHD Asthma Aparaxia Arthritis Asperger's 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 If "other" is selected, please provide information here Uses wheelchair Yes No Uses walker Yes No Wears braces Yes No Has allergies Yes No Uses crutches Yes No Has seizures Yes No Takes medication Yes No Wears contact lenses Yes No Incontinence Yes No Has special diet Yes No Loose stool Yes No Has catheter Yes No Wears helmet Yes No Has shunt Yes No Chair repositioning Yes No Comments: Please describe Communication: How does the student communicate? Please note any special signs or gestures if applicable. Does the student have behavioral outbursts? Yes No If so, please explain Does the student have a history of fighting with peers? Yes No If so, please explain Does the student exhibit aggressive/confrontational behavior (i.e. bullying, antagonizing, name calling etc.)? Yes No If so, please explain Socialization What are the student’s strengths, abilities, and talents? What kind of social outlets, if any, does the student have? Please describe any difficulties that a student may have. Please be as specific as possible. Educational Does the student like to work independently or in groups? Yes No What academic classes is the student interested in? How does the student feel about attending Next STEP?
