Member's Name Preferred Nickname Gender Male Female Age 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 Member Guardian Status Self Parent Other If "Other" is selected, please type below Parent/Guardian 1. Name 1.Parent/Guardian's 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 Home Phone # Cell Phone # Work/Business Phone # Email Parent/Guardian 2. Name 2.Parent/Guardian's 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 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” ADD ADHD Asthma 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 If other selected, please type below Uses wheelchair Yes No Uses crutches Yes No Wears braces Yes No Uses walker Yes No Has allergies Yes No Has seizures Yes No Takes medication Yes No Wears collection bag Yes No Incontinence Yes No Has special diet Yes No Has catheter Yes No Loose stool Yes No Wears helmet Yes No Has shunt Yes No Chair repositioning Yes No If Yes for Chair Repositioning, how frequently, every _ hours? 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? 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 __________________________________________________ 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 Yes No If yes, please check delivery method(s) of the PSL Services/STRIVE Newsletter Mailed Email Please contact me how I may help Yes No I am interested in fundraising (STRIVE Rocks, Annual Auction, etc.) Yes No 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 the following persons: 1. Name Relationship 2. Name Relationship Signature Date
