STRIVE Membership Form

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 #

Email

Parent/Guardian

2) Name

Address

City

State

Zip Code

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”

Other

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

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

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)

Signature *

Date *

Year

Month

Day

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

I would like to recieve the STRIVE monthly newsletter *

If yes, please check delivery method(s) of the STRIVE Newsletter

Please contact me how I may help *

Yes

No

I am interested in Fundraising (Dance Marathon, 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 *

Year

Month

Day

STRIVE Membership Form

Contact Us

STRIVE Newsletter

Support STRIVE

You are here

STRIVE Membership Form

Contact Us

STRIVE Newsletter

Support STRIVE