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Therapeutic Recreation Program Registration Form
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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,
Participant First Name
*
Participant Last Name
*
Primary Phone
*
Secondary Phone
*
Participant Address
*
Apt. Number
City
*
State
*
Zip
*
Participant Date of Birth XX/XX/XXXX
Email Address
*
Participant Residency
*
Check one:
Roanoke County
City of Roanoke
City of Salem
Other
If Other, please list:
Do you give permission for an exchange of information between TRS and Participant’s Caseworker?
*
Yes
No
Caseworker Agency
Casework Telephone
Is accessible transportation required?
*
Yes
No
Course #1
*
Program Name
Program Fee
Transportation Fee
Course #1 Transportation Pick Up/Drop Off
*
-- Select One --
None
Brambleton Center
Green Ridge
Goodwill Salem - Lakeside
Goodwill - Vinton
460 Antique Mall
Home
Would you like to register for another course?
Yes
No
Course #2
Program Name
Program Fee
Transportation Fee
Course # 2 Transportation Pick Up/Drop Off
*
-- Select One --
None
Brambleton Center
Green Ridge
Goodwill Salem - Lakeside
Goodwill - Vinton
460 Antique Mall
Home
Would you like to register for another course?
Yes
No
Course #3
Program Name
Program Fee
Transportation Fee
Couse #3 Transportation Pick Up/Drop Off
*
-- Select One --
None
Brambleton Center
Green Ridge
Goodwill Salem - Lakeside
Goodwill - Vinton
460 Antique Mall
Home
Would you like to register for another course?
Yes
No
Course #4
Program Name
Program Fee
Transportation Fee
Course #4 Transportation Pick Up/Drop Off
*
-- Select One --
None
Brambleton Center
Green Ridge
Goodwill Salem - Lakeside
Goodwill - Vinton
460 Antique Mall
Home
Would you like to register for another course?
Yes
No
Course #5
Program Name
Program Fee
Transportation Fee
Course #5 Transportation Pick Up/Drop Off
*
-- Select One --
None
Brambleton Center
Goodwill Salem - Lakeside
Goodwill - Vinton
Green Ridge
460 Antique Mall
Home
Would you like to register for another course?
Yes
No
Course #6
Program Name
Program Fee
Transportation Fee
Course #6 Transportation Pick Up/Drop Off
*
-- Select One --
None
Brambleton Center
Green Ridge
Goodwill Salem - Lakeside
Goodwill - Vinton
460 Antique Mall
Home
Would you like to register for another course?
Yes
No
Course #7
Program Name
Program Fee
Transportation Fee
Course #7 Transportation Pick Up/Drop
*
-- Select One --
None
Brambleton Center
Green Ridge
Goodwill Salem - Lakeside
Goodwill - Vinton
460 Antique Mall
Home
Would you like to register for another course?
Yes
No
Course #8
Program Name
Program Fee
Transportation Fee
Course #8 Transportation Pick Up/Drop Off
*
-- Select One --
None
Brambleton Center
Goodwill Salem - Lakeside
Goodwill - Vinton
460 Antique Mall
Home
Would you like to register for another course?
Yes
No
Course #9
Program Name
Program Fee
Transportation Fee
Course #9 Transportation Pick Up/Drop Off
*
-- Select One --
None
Brambleton Center
Green Ridge
Goodwill Salem - Lakeside
Goodwill - Vinton
460 Antique Mall
Home
Would you like to register for another course?
Yes
No
Course #10
Program Name
Program Fee
Transportation Fee
Course #10 Transportation Pick Up/Drop Off
*
-- Select One --
None
Brambleton Center
Green Ridge
Goodwill Salem - Lakeside
Goodwill - Vinton
460 Antique Mall
Home
Valentine's Dance -Additional Questions
Please answer the questions below ONLY if you are registering for an upcoming Valentine's Dinner Dance
Are you attending with a group home?
Yes
No
If attending with a group home, what is the name of your agency/home?
Do you require a sugar free dessert?
Yes
No
Do you require a specialized meal?
Yes
No
Please explain any specialized meal requirements:
Sub Total Fees ------------------------------------------->
Sub Total Program Fees
*
Sub Total Transportation Fees
*
TOTAL FEES (Program Fees + Transportation Fees) ----------------------------->
TOTAL ALL FEES
*
Payment is due before the start of programs. For registration questions please contact Therapeutic Recreation Services at (540) 772-7529 ext. 2.
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