Serving Tweens, Teens & Young Adults with Developmental Disabilities
ELIGIBILITY CRITERIA
Be a minimum of 18 years of age.
Must meet eligibility guidelines established by the Department of Health and Human Services of the State of
Maine and have the Community Supports Waiver (Section 21 or 29) or private pay at that rate.
Provide STRIVE Bayside with a completed application packet.
Applicant and parent /care provider must complete the application together.
Participate in an interview process, if STRIVE staff deems necessary.
Demonstrate an interest in possessing independent living skills, community connections, and pre-employment
experiences that are necessary to attain substantial independence.
Have a proven ability to learn and participate in small group situations.
Be willing to abide by all the rules and policies set forth by STRIVE Bayside – available upon request
QUESTIONS
Contact: Betsy Morrison
STRIVE, 28 Foden Road, South Portland ME 04103
Tel: (207) 774-6278 Fax: 207-774-7695
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Serving Tweens, Teens & Young Adults with Developmental Disabilities
APPLICATION FOR PARTICIPATION - STRIVE BAYSIDE
Please fill out the application completely. Please print clearly.
APPLICANTS Full Name: _______________________________________________________________ Sex: M______ F______
Preferred Nickname, if any: __________________________________________________________________________________
Social Security Number: __________________ MaineCare #: ________________ Date of Birth: ______________ Age: ______
Address: ___________________________________________________________________________________________________
City & State: __________________________________________________________ Zip Code: ____________________________
Home Phone: _________________________________________ Cell Phone: ___________________________________________
E-mail Address: _____________________________________________________________________________________________
Father’s/Guardian/Care Provider Name: _______________________________________Home Phone: ___________________
Address (if different from applicants): _________________________________________________________________________
Employer: ____________________________________________ Work Phone: _________________________________________
Cell Phone: ________________________ Email: __________________________________________________________________
Mother’s/Guardians Name: ______________________________________ Home Phone: _______________________________
Address (if different from applicants): _________________________________________________________________________
Employer: ____________________________________________ Work Phone: _________________________________________
Cell Phone: ________________________ Email: __________________________________________________________________
APPLICANT INFORMATION
Please complete the following section as thoroughly as possible. This information enables us to plan a safe and successful
experience for the applicant.
DISABILITIES (Please check any that apply and add any additional under “other”)
ADD ___
Autism ___
Diabetes ___
PDD ___
ADHD ___
Bi Polar ___
Dual Diagnosis ___
Quadriplegic ___
Asthma ___
Blind ___
Down Syndrome ___
Scoliosis ___
Apraxia ___
Brain Injury ___
Mental Retardation ___
Seizure Disorder ___
Arthritis ___
Cerebral Palsy ___
OCD ___
Spina Bifida ___
Aspergers ___ Deaf___
Paraplegic ___
OTHER: ____________________________________________________________________________________________
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Serving Tweens, Teens & Young Adults with Developmental Disabilities
Please circle all that apply:
Uses Wheelchair
Y
Uses Walker
Y
Wears Braces
Y
Uses Crutches
Y
Has Allergies
Y
N
N
N
N
N
Has Seizures
Takes Medication
Wears Collection Bag
Incontinence
Has Special Diet
Y
Y
Y
Y
Y
N
N
N
N
N
Has Catheter Y N
Loose Stool
Y N
Wears Helmet Y N
Has Shunt
Y N
Chair Repositioning Y N (Every ___ hours)
SELF HELP CONCERNS
 None
Toileting
Dressing
Cleanliness
Please describe in detail what assistance is needed in the areas noted above: ________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
COMMUNICATION
How does the applicant communicate? Please note any special signs or gestures if applicable.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Does the applicant use a mechanical communication device? ________ Please describe: _____________________________
____________________________________________________________________________________________________________
EQUIPMENT
Please list any equipment the applicant will be bringing with them: (ie: glasses, wheelchair etc.)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
ALLERGIES
ALLERGY
__________________________
__________________________
__________________________
__________________________
__________________________
REACTION
______________________________
______________________________
______________________________
______________________________
______________________________
TREATMENT
________________________________
________________________________
________________________________
________________________________
________________________________
BEHAVIOR
Please describe any behavioral issues: __________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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Serving Tweens, Teens & Young Adults with Developmental Disabilities
How does the applicant react to being challenged to perform or if they do not get what they desire immediately?
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Does the applicant have a history of fighting with peers? Y N If so, please explain:
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Does the applicant exhibit aggressive/ confrontational behavior (i.e. bullying, antagonizing, name calling etc.)? If so,
please explain:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Does the applicant smoke? Y N
SOCIALIZATION:
What was the type of setting the applicant spent the most time in while in school (ie. integrated, resource room, self
contained) Please share any information you feel pertinent regarding educational background and experience.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
What are the applicant strength’s, abilities, and talents? __________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What are some of the applicant’s hobbies and interests?__________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
What kind of social outlets does the applicant have? _____________________________________________________________
____________________________________________________________________________________________________________
Please describe any social difficulties that the applicant may have. Please be as specific as possible.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
INDEPEDENCE
Does the applicant use public transportation? (e.g., city bus): ______________________________________________________
Does the applicant have a Driver’s License? ____________________________________________________________________
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Serving Tweens, Teens & Young Adults with Developmental Disabilities
What is the applicant’s current living situation? _________________________________________________________________
Does the applicant spend any time at home alone? _______________________________________________________________
EMPLOYMENT
Is the applicant currently employed: Y N If so, please describe current position and job responsibilities: ______________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Please list any other work experience with duration of employment: _______________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
How did these work experiences end? _________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
If the applicant does not currently work, would they like to have a job in the future and, if so, what kind of a job: ________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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___/_____/____
____________________________________ ______________________________________
Date Signature: Participant if over 18, or legal Guardian Print name of Participant/Legal Guardian
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Serving Tweens, Teens & Young Adults with Developmental Disabilities
Applicant’s Personal Essay
For you to be the most successful in the STRIVE Bayside Program there are three important things that need to happen:
1.
2.
3.
STRIVE Bayside needs to provide you with an organized and individualized program to assist you to
meet your full potential in areas of independent living skills and accessing your community.
You have to have the desire and commitment to want to learn these skills over the next two years.
Your family/care provider has to be committed to supporting you both at STRIVE Bayside but more
importantly for you to use the skills you learn in the community and home in which you live.
With your family/care provider please tell us in 200 words or less why you want to attend STRIVE Bayside and what you
hope to accomplish both at the program and in your home and community.
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