Virginia Department for Aging and Rehabilitative Services Federal Traumatic Brain Injury Grant Presents “We Walk Together” Hilton Garden Inn at Innsbrook, Glen Allen VA November 16, 2013 – 10:00 a.m. to 4:00 p.m. Caregiver Forum Registration Form Limited Space - Register by Wednesday, October 30, 2013! Please fill out the information below to become a confirmed participant. You will receive a confirmation email once the form is received by the Brain Injury Association of Virginia (BIAV). If you have questions, contact Jennifer Clarke via email: [email protected] or voice: 804-355-5748 or 800-444-6443. PART 1: CAREGIVER / PROFESSIONAL Name(s): *If two caregivers from a family are attending, please be sure both full names are provided on this form. I am a: □Caregiver □Professional □Both □Other (specify): *Please note, priority registration will be given to caregivers and family members. If you are a professional interested in attending, you may be placed on a waitlist. Address: Home Phone: Business/Cell Phone: E-mail: Special Accommodation(s) Requested: ________________________________________________________________________________________________________________________________________________________________________________________ PART 2: SURVIVOR (INDIVIDUAL WITH AN ACQUIRED BRAIN INJURY) 1. Will you be bringing your loved one who is a survivor of Brain Injury? □Yes □No Name of survivor: Date of birth: 2. Are you requesting that your loved one with a brain injury participate in the separate Survivor Activities that are offered (same hotel, different room)? □Yes □No 3. Level of Functioning*: □Mild (limited to no physical or verbal assistance needed) □Moderate (some physical or verbal assistance needed) □Severe (physical and verbal assistance needed) *Bathroom assistance: We will not be able to assist anyone with toileting, including transferring from wheelchair to commode. *Special medical needs: We are not able to administer medication or assist with medical procedures. If your loved one has a personal assistant that provides care to the individual, both may attend the special activities. 4. Does your loved one require any accommodations or special assistance to participate in the Survivor Activities? □Yes □No If YES, please describe what help or accommodations the survivor will need: 5. Ambulatory (able to walk unassisted): □Yes □No If NO, describe: 6. Are there any behavioral concerns: □Yes □No If YES, explain: 7. Any other information that you would like to share regarding your loved one with a brain injury that the staff would need or like to know: Part 3: Lodging Hotel accommodations will be provided at NO COST for caregivers who must travel at least 12o miles one way to the Caregiver Forum. If you qualify, you will be notified of your hotel reservation for the night of Friday, November 15, 2013. Hotel reservations must be cancelled by 5pm on Thursday, November 14, 2013 to avoid penalties, for which you as the individual will be responsible (DARS and BIAV are not able to pay cancellation fees) to pay. 1. Are you requesting FREE hotel lodging (circle one)? □Yes □No If NO, skip to Part 4! 2. If YES, the number of miles you are traveling to the Hilton Garden Inn in Glen Allen, VA (this determines whether you are eligible to receive a per diem stipend to pay for lodging and mileage): . 3. Are you requesting lodging for: □Yourself ONLY □Yourself and a Loved One with BI 4. Will you need a room that is handicapped accessible? □Yes □No (Note that all handicapped accessible rooms have one King bed.) 5. Will you need an extra roll away bed? □Yes □No 6. Will you need a smoking room? □Yes □No Part 4: Meals A continental breakfast and lunch will be provided for all participants at the Caregiver Forum. 1. Do you (or your loved one) have special dietary needs? □Yes □No If YES, please describe special dietary needs and indicate name of person: Supported by Grant number H21MC06763-07-03 from the Department of Health and Human Services (DHHS), Health Resources and Services Administration, Maternal and Child Health Bureau. The contents are the sole responsibility of the authors and do not necessarily represent the official views of DHHS or DARS. Limited Space: Register by October 30, 2013! Return form to Jennifer Clarke at the Brain Injury Association of Virginia. Email: [email protected] or Fax to (804) 355-6381. For additional information you can also contact Kristie Chamberlain at the Virginia Department for Aging & Rehabilitative Services: Email: [email protected]
Posted on: Thu, 10 Oct 2013 09:24:18 +0000
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