Therapeutic Recreation Program Registration Form

2. Please review all information in the TRS brochure to ensure you are registering for appropriate programs according to descriptions and guidelines. All new participants must complete an Assesment with a TRS staff and a Participant Health Form before participating in TRS programs. Registrations will be processed the morning of registration in the order in which they were received, and may be submitted prior to the registration date. You may submit up to 10 courses on this form,
4. Participant First Name*
5. Participant Last Name*
7. Primary Phone*
8. Secondary Phone*
10. Participant Address*
11. Apt. Number
13. City*
14. State*
15. Zip*
17. Participant Date of Birth XX/XX/XXXX
18. Email Address*
20. Participant Residency*

    Check one:

    1. Roanoke County
    2. City of Roanoke

    1. City of Salem
    2. Other
22. If Other, please list:
24. Do you give permission for an exchange of information between TRS and Participant’s Caseworker?*

    1. Yes
    2. No
26. Caseworker Agency
27. Casework Telephone
29. Is accessible transportation required?*

    1. Yes
    2. No
31. Course #1*
32. Program Name
33. Program Fee
34. Transportation Fee
37. Course #1 Transportation Pick Up/Drop Off*
    -- Select One --NoneBrambleton CenterGreen RidgeGoodwill Salem - LakesideGoodwill - Vinton460 Antique MallHome
39. Would you like to register for another course?

    1. Yes
    2. No
43. Course #2
44. Program Name
45. Program Fee
46. Transportation Fee
49. Course # 2 Transportation Pick Up/Drop Off*
    -- Select One --NoneBrambleton CenterGreen RidgeGoodwill Salem - LakesideGoodwill - Vinton460 Antique MallHome
51. Would you like to register for another course?

    1. Yes
    2. No
55. Course #3
56. Program Name
57. Program Fee
58. Transportation Fee
61. Couse #3 Transportation Pick Up/Drop Off*
    -- Select One --NoneBrambleton CenterGreen RidgeGoodwill Salem - LakesideGoodwill - Vinton460 Antique MallHome
63. Would you like to register for another course?

    1. Yes
    2. No
67. Course #4
68. Program Name
69. Program Fee
70. Transportation Fee
73. Course #4 Transportation Pick Up/Drop Off*
    -- Select One --NoneBrambleton CenterGreen RidgeGoodwill Salem - LakesideGoodwill - Vinton460 Antique MallHome
75. Would you like to register for another course?

    1. Yes
    2. No
79. Course #5
80. Program Name
81. Program Fee
82. Transportation Fee
85. Course #5 Transportation Pick Up/Drop Off*
    -- Select One --NoneBrambleton CenterGoodwill Salem - LakesideGoodwill - VintonGreen Ridge460 Antique MallHome
87. Would you like to register for another course?

    1. Yes
    2. No
91. Course #6
92. Program Name
93. Program Fee
94. Transportation Fee
97. Course #6 Transportation Pick Up/Drop Off*
    -- Select One --NoneBrambleton CenterGreen RidgeGoodwill Salem - LakesideGoodwill - Vinton460 Antique MallHome
99. Would you like to register for another course?

    1. Yes
    2. No
103. Course #7
104. Program Name
105. Program Fee
106. Transportation Fee
109. Course #7 Transportation Pick Up/Drop*
     -- Select One --NoneBrambleton CenterGreen RidgeGoodwill Salem - LakesideGoodwill - Vinton460 Antique MallHome
111. Would you like to register for another course?

     1. Yes
     2. No
115. Course #8
116. Program Name
117. Program Fee
118. Transportation Fee
121. Course #8 Transportation Pick Up/Drop Off*
     -- Select One --NoneBrambleton CenterGoodwill Salem - LakesideGoodwill - Vinton460 Antique MallHome
123. Would you like to register for another course?

     1. Yes
     2. No
127. Course #9
128. Program Name
129. Program Fee
130. Transportation Fee
133. Course #9 Transportation Pick Up/Drop Off*
     -- Select One --NoneBrambleton CenterGreen RidgeGoodwill Salem - LakesideGoodwill - Vinton460 Antique MallHome
135. Would you like to register for another course?

     1. Yes
     2. No
139. Course #10
140. Program Name
141. Program Fee
142. Transportation Fee
145. Course #10 Transportation Pick Up/Drop Off*
     -- Select One --NoneBrambleton CenterGreen RidgeGoodwill Salem - LakesideGoodwill - Vinton460 Antique MallHome
149. Valentine's Dance -Additional Questions
     Please answer the questions below ONLY if you are registering for an upcoming Valentine's Dinner Dance
151. Are you attending with a group home?

     1. Yes
     2. No
152. If attending with a group home, what is the name of your agency/home?
154. Do you require a sugar free dessert?

     1. Yes
     2. No
155. Do you require a specialized meal?

     1. Yes
     2. No
157. Please explain any specialized meal requirements:
161. Sub Total Fees ------------------------------------------->
162. Sub Total Program Fees*
163. Sub Total Transportation Fees*
165. TOTAL FEES (Program Fees + Transportation Fees) ----------------------------->
166. TOTAL ALL FEES*
168. Payment is due before the start of programs. For registration questions please contact Therapeutic Recreation Services at (540) 772-7529 ext. 2.
Leave This Blank:


170. Submit Submit and Print

* indicates a required field