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TRS Participant Info Form

  1. Do you give permission for an exchange of information between TRS and your case worker?

  2. Medical and Disability Information

  3. Please select any assistive mobility devices used:

  4. Wheelchair user - Able to trasfer?

  5. Wheelchair user - Motorized or manual?

  6. Visual Impairment?*

  7. Able to read braille?

  8. Sighted guide needed?

  9. Hearing impairment?*

  10. Sign language user?

  11. Wearing hearing aids?

  12. Speech Impairment?*

  13. Communication device?

  14. Seizure disorder?*

  15. Allergies?

  16. Daibetes?*

  17. Communicable disease?*

  18. Medications: (Please note TRS staff do not adminsiter)

  19. Photo Release

  20. 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.*

  21. 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.

  22. Leave This Blank:

  23. This field is not part of the form submission.