STRIVE Tweens Membership Form

1 Start 2 Complete

OVERVIEW:
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 STRIVE 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 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 STRIVE with a completed application packet prior to participation in programs.

Demonstrate an interest in participating in STRIVE programs.

In order to keep STRIVE a safe place, 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 QUESTIONSContact Olivia Fraioli, STRIVE Team Leaderofraioli@pslstrive.org

Membership form

Contact Information

Member's Full 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

If "Other" is selected, please type below

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

Please answer "Yes" or "No" for all that apply:

Uses wheelchair *

Yes

Uses crutches *

Yes

Wears braces *

Yes

Uses walker *

Yes

Has allergies *

Yes

Hes 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 concerns

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

Yes

If so, please explain:

Any hospitalizations due to non - medical reasons? *

Yes

If so, please explain:

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PHOTO RELEASE

Signature

Date

Year

Month

Day

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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