The Arc TFIL Metro Trip Registration Form 2022/2023

TFIL Metro Trip Registration Form 2022/2023

We're so excited for you to join us on a metro trip! Please fill out this form and if you have questions, contact our Technology for Independent Living team at techforindependence@thearcofnova.org
Please indicate what date you will be taking the Metro Trip. You are able to chose multiple dates if you would like.

January 6, 2023February 3, 2023March 3, 2023April 7, 2023June 2, 2023
Individual with Disability Information
Name

First NameLast Name
Age
Disability Information - Check all that apply

Autism Spectrum Disorder or Asperger's SyndromeDown SyndromeOther Intellectual/Developmental DisabilityBlind or Visually ImpairedHearing ImpairedMobility Impaired
Do you require an elevator to travel on the metro?

YesNo
Cell Phone

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select the jurisdiction in which you live.

Fairfax CountyCity of Falls ChurchCity of AlexandriaArlington CountyPrince William CountyLoudoun CountyMontgomery CountyPrince George's CountyWashington, DCOther
Work/School Information-Check all that apply

Attends school (High School)Attends school (College or University)WorksAttends a Day Service or Vocational Program
Primary Language (Please specify language if not listed)

EnglishSpanishSign Language
Primary Communication:

VerbalNonspeakingAugmentative and Alternative Communication (High or Low Tech Communication Devices)
Demographics for our grants - Please select the ethnicity options that best matches how you identify.

Hispanic or Latino/LatinaNot Hispanic or Latino/LatinaI prefer not to provide this information
Demographics for our grants - Please select the race option that best matches how you identify.

White/CaucasianBlack/African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian & Other Pacific IslanderMultiracialI prefer not to provide this informationOther
Demographics for our grants - Please select all that apply to your household.

Female headed householdIncludes child(ren) under 18Includes person(s) with a disability (physical or mental impairment that substantially limits one or more major life activities.)Includes person(s) age 55 or olderIncludes unemployed person(s) (not dependents in high school or below)Enrolled in TANF (Temporary Assistance for Needy Families)I prefer not to provide this information
Dedicated Adult Information
How would you classify yourself.

Parent of an adult (22 and older) with a disabilityParent of a child (21 and younger) with a disabilitySibling of a person with a disabilityOther relative of a person with a disabilityDisability professional (includes educators, providers, therapists, attendants, interns, etc.)Other
Dedicated Adult Family Member (parent, sibling, etc.)

First NameLast Name
Dedicated Adult Family Member Contact Information (parent, sibling, etc.)

Area CodePhone Number
Dedicated Adult Family Member Email
example@example.com
Gender

MaleFemaleTransgenderNon-Binary/Non-Conforming
Other Information

0/75
Prior to today, have you previously engaged in any of these activities since July 1, 2022. (Please select all that apply)

Webinar or workshopWebsite information and resourcesTransition POINTS resources guidesSpecial Needs Trust programTech for Independent Living ProgramEmail/phone call/meeting with staffI have not participated in any of these activities during this time frame.Other
Any other information you would like us to know?
Media Release
I give my consent to The Arc of Northern Virginia to use information about me, my name, my child's name, photograph, and/or voice for media and public relations purposes. I understand that by the term media, this my include television, radio, newspaper articles, brochures, flyers, social media (including Facebook and Twitter), website, weblog, or other related sources of publicity for The Arc of Northern Virginia or its participants. Furthermore, I understand that the purpose of using my name, photograph, voice, ort other information about me or my family members, is to educated and inform the general public about The Arc of Northern Virginia and its activities and its participants.
Response

I agreeI do not agree
Should be Empty:

TFIL Metro Trip Registration Form 2022/2023

Individual with Disability Information

Dedicated Adult Information

Media Release