New TRP Intake
First Name *
Last Name *
Date of Birth *
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Preferred Pronouns *
Street Address *
City *
State *
Zip *
Phone Number (xxx)-xxx-xxxx *
Email *
Branch of Service *
Era of service *
Service Status *
SCUBA Certification Agency *
SCUBA Certification Agency # *
Current Scuba Certification Level *
Goals for Participation *
Do you have any physical, psychological, or special needs that may effect your ability to scuba dive? *
How many days a week do you currently exercise 30 minutes or more? *
Do you have any alterations in hearing or vision? *
Do you require assistance getting into a boat or transitioning to a seated position on the ground? *
Do you have any needs or preferences for learning new information? If yes, please explain. *
What expectations do you have of coaches or volunteers? *
What is your current level of gross income? *
Are you affiliated with, or a beneficiary of, any other veteran non-profit organization?   *
If yes, please list those organizations.
The below section of the form is all voluntary disclosure. It is not required to be provided, nor does the information impact or influence membership decisions. The purpose of this data collection is in the spirit of ensuring we are performing our social responsibilities to everyone. Additionally, this information helps us report our inclusion and diversity performance to the government and donors for grants and sponsorships. That being said, we would very much appreciate if you would elect to self identify for the below questions. Note that this information is confidential and will not be shared to anyone outside TRP Board Membership. The use of the information will only be in the statistical aggregation for grants and sponsorship (no identifying data).
Please specify your current level of service connected disability - i.e 80% PTSD, 10% Tinnitus, ect.. 
Do you need assistance with obtaining benefits from the Veteran Benefits Administration?
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What is your current job status?
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Are you satisfied with your current level of employment?
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Per the previous question, if no, do you have plans to seek alternate career opportunities?
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What is your level of education?
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Do you have plans, or are you interested in continuing your education? 
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Per the previous question, if yes, please indicate what your educational goals are. If no, please specify your reasoning.
Do you grant the TRP the right and permission to take photographs and videos during TRP events and activities and to use and publish in media, including the internet (and social media)? *
I understand my participation in SCUBA diving is a physically demanding activity where there may be unusual risk to my health and safety.
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Please type name below this indicates an electronic signature as agreement to the above waiver *
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