OVERVIEW: PSL Services/STRIVE is a non-profit organization that focuses on serving teens and young adults with developmental disabilities through socialization, education and employment training opportunities. Tweens is one of STRIVE’s newer programs created in direct response to a need for social activities for middle aged students. STRIVE Tween Socials are held at PSL Services/STRIVE center from 3:30 to 5:30pm every Friday. This program is specifically designed for 11 to 14 year olds and is modeled after the STRIVE Friday Night Socials. CANCELLATION POLICY: In the event of a Tween Social cancellation, a decision will be made by 1pm on that Friday and posted here on the PSL Services/STRIVE website: www.pslstrive.org, as well as run on the local television news tickers. If you have questions please feel free to call the office at 207-774-6278. ELIGIBILITY CRITERIA Be 11-14 years old to participate in the Tweens program. Student must be able to provide personal care and/or provide support to assist. Provide PSL Services/STRIVE with a completed application packet prior to participation in programs. Demonstrate an interest in participating in STRIVE programs. In order to keep PSL Services/STRIVE a safe place, PSL Services/STRIVE retains the right to decide if a member needs to be accompanied by a guardian or if appropriate staff is required. FOR MORE INFORMATION OR QUESTIONS Contact Olivia Fraioli, PSL Services/STRIVE Team Leader ofraioli@pslstrive.org Membership form Contact Information Member's Full 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 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 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 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 Other Uses wheelchair Yes No Uses crutches Yes No Wears braces Yes No Uses walker Yes No Has allergies Yes No Hes 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 Does the student exhibit aggressive/ confrontational behavior (i.e. bullying, fighting, antagonizing, name calling etc.)? Yes No If so, please explain: Any hospitalizations due to non - medical reasons? 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 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
