Next Step Fund, Inc.

STRIVE (2025-2026 academic year)
2025-09-29 - 2026-05-02
Next Step STRIVE is a FREE weekly mentorship program for teens, ages 13-18, living with a chronic illness in Boston, Washington, D.C., New York City, New Haven and Philadelphia. As a STRIVE student, you’ll get one-on-one academic support and access to a community of peers in a safe and welcoming environment. Sound cool? Sign up below and join us!

Here’s what you can do at STRIVE each week:
1. Get Homework Help When You Need It
Attend weekly virtual sessions with a dedicated mentor.
2. Connect and Destress with Friends Who Get It
Attend a bi-monthly in-person programs focused on community building and fun.
3. Learn, Collaborate and Give Back Together
And once a month, STRIVE students from Boston, Washington D.C., New York City, New Haven and Philadelphia meet online for some real talk—and action! You might hear from a panel of young adults living with a chronic illness, learn tips for health management, work together on a community service project to lift the spirits of kids in the hospital or maybe even write a song together.

Sign up to join Next Step STRIVE
Next Step STRIVE groups meet from September 29th through May 2nd. Just hearing about STRIVE? No problem, you can join anytime—there’s no deadline. Sign up by filling out the short form below and one of our team members will be in touch with more details to get you started.
Still have questions?
Email Richard Martinez, Next Step Mentorship Coordinator, at richard@nextstepnet.org

STRIVE Registration

What city program are you applying for:*

Boston Area

New York City Area

Washington D.C. Area

New Haven, CT Area

Philadelphia, PA Area
STRIVE is for teens, 13-18 year-olds, living with a chronic illness. For more info please call Kepler at 617-864-2921Have you been to a Next Step program before?*

Yes

Attended Introductory Event Only (e.g. Next Step Mobile at hospital, community center, etc.)

No
How did you hear about the Next Step program?*

Next Step Outreach (Email or Event)

Google/Internet Search

Social Media (Instagram, etc)

Family Member/Trust Adult

Another Participant

Medical Staff

Other

If medical staff, please include name, position and hospital:*Name of STRIVE Participant*

First

Last

NicknameAddress*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

Phone*Child's Cell PhoneEmail*

Preferred mode of contact?*

Email

Cell Phone (Call)

Cell Phone (Text)
Child's SchoolAt What Time Does Your Child Leave for School?How Does Your Child Get Home from School?Child's Homeroom TeacherChild's GradeAgeChild's Birthday

MM slash DD slash YYYY

Race/EthnicityGenderPronouns (he/him, she/her, they/them)Hospital or Clinic where your child receive medical care?What do you/your child hope to get out of the Next Step STRIVE experience?What topic(s) do you/your child most want to learn about at STRIVE?Environmental Allergies (bee, latex, etc) & ReactionsDo your child carry an Epi-Pen?

Yes

No
Food Allergies & ReactionsWhat is your child's diagnosis?*Are there are any special accommodations your child would need (dietary, mobility, equipment, etc.)? Please explain:Are there any activity limitations?PARENT/GUARDIAN AND EMERGENCY CONTACTName*

First

Last

RelationshipPhoneEmail

INFORMED CONSENT FORMBefore my child can be accepted into the Program, I understand that I must

Discuss my child’s participation in the Program with his/her regular health care provider
While my child is at STRIVE

I understand that my child may undergo physical exertion while participating in the Program, and that there are possibilities of injury or other complications associated with exercise

I understand that no physician or medically trained individual will be present during the Program

I understand that in the event physical injury occurs while my child is participating in the Program, medical treatment and assistance will be available in the same manner and to the same extent available for injuries that my child may suffer were he/she not enrolled in the Program

I understand that no compensation for the cost of the treatment or other losses that my child may suffer can be or is guaranteed

In the case of an emergency or should your child have any complication from SCD while at the program in any way, Program volunteers will seek immediate emergency medical assistance and promptly inform the Next Step's Mentorship Coordinator, Richard Martinez, of the incident

I agree to waive and release all claims and causes of action that I may have or acquire against Next Step and/or any of their trustees, officers, employees, agents or volunteers for injury, loss, or damage which I or my child may suffer which are in any way connected with participation in the Program.

I hereby allow my child to participate in the Program. I understand that my consent will remain effective until either my child completes the Program, or I withdraw my child from the Program.
STRIVE QuestionaireHow much does your child know about sickle cell anemia?*

Not much

A little

A lot
What activities does your child like to do?How many school days has your child missed due to sickle cell?Are there challenges that your child has experienced at school that you would like to share with us?What subjects would your child like extra help on during tutoring time? Is your child taking any standardized tests this school year? If yes, which one(s)?Is there an activity that you would be uncomfortable with or would prefer your child not to participate in?PHOTO AND INFORMATION RELEASEI give Next Step permission to photograph and use pictures or visual and/or audiotapes of me in professional or fundraising activities. On occasion, with this permission, participant photographs may be included on the Next Step website, on a bulletin board, video, newsletter, campference album, or in personal photographs. Next Step respects the privacy of participants and does not allow unauthorized visitors to photograph the campference or participants. In addition, by signing below, I give Next Step permission to give my name, address and/or phone number to groups or individuals wishing to support Next Step by inviting me to an event or by sending me information related to Next Step. This list will not be sold or given to anyone else for any other reason.Please check appropriate box and provide your signature below:*

I agree to the photo release

I do not agree to the photo release
Please SignBy signing below, I hereby acknowledge that I have read and fully understand the terms and expectations of the program. All information provided is current and accurate to the best of my knowledge.Name*

First

Last

Date*

MM slash DD slash YYYY

Please check this box to indicate that the above signature will serve as your electronic signature

(Delegate or Legal Guardian if the Delegate is not over the age of 18)

Δ
