2. Participant Name:*
3. Birthdate (DD/MM/YYYY)*
5. Email*
6. Primary Phone*
7. Secondary Phone
9. Address*
10. City*
11. State*
12. Zip Code*
14. Residency*
    -- Select One --Roanoke CountyCity of RoanokeCity of SalemOther
15. Please specify "other" municipality:
17. Legal Guardian (if applicable)
18. Legal Guardian's Phone
20. Case Worker's Name
21. Case Worker's Phone
22. Organization
24. Do you give permission for an exchange of information between TRS and your case worker?

    1. Yes
    2. No
26. Emergency Contact 1 Name*
27. Emergency Contact 1 Phone*
28. Emergency Contact 1 Relationship*
30. Emergency Contact 2 Name*
31. Emergency Contact 2 Phone*
32. Emergency Contact 2 Relationship*
34. Describe Participant's Primary Disability*
35. Describe Participant's Secondary Disability
37. Medical and Disability Information
39. Please select any assistive mobility devices used:

    1. Walker
    2. Cane
    3. Wheelchair
40. Wheelchair user - Able to trasfer?

    1. Yes
    2. No
41. Wheelchair user - Motorized or manual?

    1. Motorized
    2. Manual
43. Visual Impairment?*

    1. Yes
    2. No
44. Able to read braille?

    1. Yes
    2. No
45. Sighted guide needed?

    1. Yes
    2. No
47. Hearing impairment?*

    1. Yes
    2. No
48. Sign language user?

    1. Yes
    2. No
49. Wearing hearing aids?

    1. Yes
    2. No
51. Speech Impairment?*

    1. Yes
    2. No
52. Communication device?

    1. Yes
    2. No
53. Type of device?
55. Seizure disorder?*

    1. Yes
    2. No
56. Please describe seziure
57. Please give instructions if participant has a seizure during program:
59. Allergies?

    1. Food
    2. Medial
    3. Other (bee sting/ latex, etc)
60. Please explain alergies:
62. Daibetes?*

    1. Yes
    2. No
63. Communicable disease?*

    1. Yes
    2. No
64. Please explain: (AIDS, HIV, etc)
66. Medications: (Please note TRS staff do not adminsiter)
68. Medication Name
69. Dose
70. Times
71. Purpose
73. Medication 2 Name
74. Medication 2 Dose
75. Medication 2 Times
76. Medication 2 Purpose
78. Medication 3 Name
79. Medication 3 Dose
80. Medication 3 Times
81. Medication 3 Purpose
83. Medication 4 Name
84. Medication 4 Dose
85. Medication 4 Times
86. Medication 4 Purpose
88. Medication 5 Name
89. Medication 5 Dose
90. Medication 5 Times
91. Medication 5 Purpose
93. Medication 6 Name
94. Medication 6 Dose
95. Medication 6 Times
96. Medication 6 Purpose
98. Photo Release
100. In accordance with section 8.01-40 of the Code of Virginia, I hereby give permission to be photographed during program participation, and I give the department permission to use or distribute such photographs and identification.*

     1. Yes
     2. No
102. This information will be used for emergencies only, and will be given to EMT staff if required. All information on this form will be kept confidential and will not be shared without the participant’s consent.
Leave This Blank:


104. 1. Receive an email copy of this form.
105. Email address

     This field is not part of the form submission.

106. Submit

* indicates a required field