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Allows Participant to attend monthly social events free of charge; receive a reduced rate for the bowling league, baseball league, life skills workshops, and other programs; and receive the monthly newsletters. Annual membership runs July 1-June 30. Any participant who signs up on or after April 1st is included in next year.

Date

Southwest Florida Seasonal Dates (if applicable)

Participant Name

First Last

Nickname

Parent/Guardian Name

First Last

Permanent Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

SWFL Seasonal Address (if applicable)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Mailing Address (For the Newsletter if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are You on Social Media

Yes
No

Platforms

Facebook
Twitter
Instagram

Other

How did you first hear about STARability?

How long have you been a member at STARability?

Medical Information

Allergies (Food & Other)

Medications

Diabetic

Yes
No

Seizures

Yes
No

If "Yes," list type of seizure

Date of Last Seizure

Emergency Contact

Name of First Emergency Contact

First Last

Relationship

Phone

Name of Second Emergency Contact

First Last

Relationship

Phone

Authorization for Treatment

Consent

I hereby give consent to any medical facility and/or physician to administer necessary treatment to my child/participant in the event that I cannot be contacted. I give consent to transport by ambulance if the situation warrants.

Typed Name of Parent/Guardian

First Last

Date

Participant Survey 2020-2021

The following information is being requested for planning purposes and for collecting aggregate data for grants. Individual participants will not be identified and their information will not be shared by STARability with any third party.

Participant Name

First Last

Participant Birthday

T-Shirt Size

Age

Must be at least 14 years or older to participate in this program.

Date of Birth

Gender

Female
Male

Ethnicity

Registered with APD (Agency for Persons with Disability)

Yes
No

Receive funding through FL's Medical Program (Med Waiver)?

Yes
No

If yes, Med Waiver Support Coordinator:

Receive Social Security Disability Income (SSDI)?

Yes
No

Diagnosis

Check all that apply.

Autism Spectrum Disorder
Cerebral Palsy
Down Syndrome
Fragile X Syndrome
Intellectual Disability
Spina Bifida
TBD
Other

If other, please specify:

Behavioral Concerns

Explain any behavioral concerns and impact on functioning (including any triggers and best method of resolution).

Communication skills. Check all that apply.

ASL
Facial
Gestures
Picture Board
Speech
Vocal Sounds

Primary Language

Secondary Language

Community Access

Does this person use a wheelchair in the community?

Yes
No

Use the bus system?

Yes
No

If yes, C.A.T. or ParaTransit

Currently volunteering?

Yes
No

Number of Hours Per Week?

Place(s) this person volunteers

Currently employed?

Yes
No

Number of Hours Per Week?

Place of Employment?

Is this person seeking employment?

Yes
No

Experience/Skills?

Attend a day program?

Yes
No

If yes, name of day program?

Interests/Activities?

Please check which programs/activities this person is interested in participating in during this year.

Interests/Activities

Other activities you would like to see STARability provide?

Do you participate in special olympics?

Yes
No

Would you like this person to be placed on the waitlist for the Trailblazer Academy?

Yes
No

Housing

Who does this person live with?

Family
ICF Family
On their own
Group home
Nonrelative/Caregiver
Other

If other please specify.

Does this person have any current or future housing needs?

Yes
No

Please describe:

Have you made plans for long-term housing for your dependent?

Yes
No

Would you be interested in a long-term housing solution in Collier County, if one were provided?

Yes
No

When considering a long term housing option, please rank the following factors from 1-5, with 1 being the most important: Cost, Apartment Style, Living Independently, Access to Services and Amenities, Group Home, Other

Photo/Video Release

We strive to help educate people on what we do and to bring public awareness to our organization. Occasionally the news/media writes stories about STARability. Photos/videos are frequently posted on our website and social media, and in our brochures and newsletters.

Do you give STARability permission to post first name?

Yes
No

Do you give STARability permission to post photo?

Yes
No

Do you give STARability permission to post video?

Yes
No

Payment

Payment is accepted through PayPal. You do not need to have an account with PayPal to use this feature. Simply sign in as a guest.

Annual Enrollment Fee:*

$75 for one participant
$95 for a family with two participants

ENROLL TODAY

Medical Information

Emergency Contact

Authorization for Treatment

Participant Survey 2020-2021

Diagnosis

Community Access

Interests/Activities?

Housing

Photo/Video Release

Payment

Contact Us

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ENROLL TODAY

Medical Information

Emergency Contact

Authorization for Treatment

Participant Survey 2020-2021

Diagnosis

Community Access

Interests/Activities?

Housing

Photo/Video Release

Payment

Contact Us

Get The Latest News

Subscribe To Our Newsletter

Thanks! You've successfully subscribed.

Follow us

About Us

Pin It on Pinterest