STRIVE Membership Form

Gender
Address
Member Guardian Status

Parent/Guardian

1.Parent/Guardian's Address

Parent/Guardian

2.Parent/Guardian's Address

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”
Uses wheelchair
Uses crutches
Wears braces
Uses walker
Has allergies
Has seizures
Takes medication
Wears collection bag
Incontinence
Has special diet
Has catheter
Loose stool
Wears helmet
Has shunt
Chair repositioning
Please list the food, reaction, and treatment as applicable

Behavioral Concerns:

Any hospitalizations due to non - medical reasons?
Does the student exhibit aggressive/confrontational behavior (i.e. bullying, antagonizing, name calling, etc.)?

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Photo Release:

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I would like to recieve the PSL Services/STRIVE monthly newsletter
If yes, please check delivery method(s) of the PSL Services/STRIVE Newsletter
Please contact me how I may help
I am interested in fundraising (STRIVE Rocks, Annual Auction, etc.)

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: