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 CenterGoodwill 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 CenterGoodwill 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 CenterGoodwill 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 CenterGoodwill 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 ransportation Pick Up/Drop Off*
    -- Select One --NoneBrambleton CenterGoodwill Salem - LakesideGoodwill - Vinton460 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 CenterGoodwill 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 CenterGoodwill 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 CenterGoodwill 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 CenterGoodwill 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

     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:


169. Submit Submit and Print

* indicates a required field