STRIVE Membership Form

1 Start 2 Complete

Member's Name *

Preferred Nickname

Gender *

Male

Female

Age *

Date of Birth *

Year

Month

Day

Email *

Phone # *

Address *

City *

State *

Zip Code *

Member Guardian Status *

Self

Parent

Other

Please type other here

Parent/Guardian

1) Name

Address

City

State

Zip Code

Home Phone #

Cell Phone #

Work/Business Phone #

Parent/Guardian

2) Name

Address

City

State

Zip Code

Home Phone #

Cell Phone #

Work/Business Phone #

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

Other

Uses wheelchair *

Yes

Uses crutches *

Yes

Wears braces *

Yes

Uses walker *

Yes

Has allergies *

Yes

Has seizures *

Yes

Takes medication *

Yes

Wears collection bag *

Yes

Incontinence *

Yes

Has special diet *

Yes

Has catheter *

Yes

Loose stool *

Yes

Wears helmet *

Yes

Has shunt *

Yes

Chair repositioning *

Yes

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

Behavior Concerns

Please describe any behavioral issues

Any hospitalizations due to non - medical reasons? *

Yes

If so, please explain

Does the student exhibit aggressive/confrontational behavior (i.e. bullying, antagonizing, name calling, etc.)? *

Yes

If so, please explain

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PHOTO RELEASE

Signature *

Date *

Year

Month

Day

******************************************************

Please contact me how I may help *

Yes

I am interested in Fundraising (Dance Marathon, Annual Auction, etc.) *

Yes

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 *

Year

Month

Day

Upcoming Events

Wednesday Night Educational Series: Career Exploration

Wednesday, December 19, 2018 - 6:00pm to 8:00pm
Tweens Social

Friday, December 21, 2018 - 3:30pm to 5:30pm
STRIVE Friday Night Social

Friday, December 21, 2018 - 6:00pm to 9:00pm
STRIVE Closed - Happy Holidays!

Tuesday, December 25, 2018 (All day)
Tweens Social

Friday, December 28, 2018 - 3:30pm to 5:30pm