TALMAR FY24 participant & volunteer data

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demographic data for everyone engaged with TALMAR in FY24 starting July 1, 2023

I am registering as a: *

program participant (including VA FARMS)

volunteer

1:1 or other support aide accompanying a program participant or volunteer with disabilities

Email *

Participant, volunteer, or support person's name *

Name of person submitting the form if other than participant or volunteer *

Date of Birth *

YYYY

best contact phone

would you like to receive news and updates from TALMAR? *

Yes

Organizational Referral

Address *

zip code *

County (or Baltimore City) *

Does the participant or volunteer have a disability or mental illness? *

Yes

Diagnosis 1

Diagnosis 2

Diagnosis 3

Diagnosis 4

Are there any medical or health factors or conditions that might affect participant’s performance in activity? If yes, explain.
*

Is participant taking any medications or have a condition that may affect participant’s safety or performance in the activity? If yes, explain.
*

Does the participant or volunteer require any special accommodations (due to disability) to participate in the activity? If yes, explain.
*

In case of injury or emergency, I, for myself and/or participant (if participant is minor/child), and my personal representatives, heirs and assigns, (severally and collectively “I”) for this registration form give permission for an activity representative to call 911 and transport participant to a hospital. I shall inform TALMAR in writing, of any medical or health conditions of participant that occurs or develops and which could affect participant’s safety, performance or participation in or throughout the activity.
*

Yes

Is the primary income earner and decision maker in the household female?
*

Yes

Is the participant's ethnicity:
*

Hispanic

Non-Hispanic

What is the participant's race?
*

American Indian or Alaskan Native

Asian

Black or African American

White

American Indian or Alaskan Native and white

Asian and White

Black or African American and white

other multi-racial

Native Hawaiian or Pacific Islander

Do you speak a language other than English at home?
*

Yes

If yes, what is this language?

If you speak another language at home, how well do you speak English?

very well

well

not well

not at all

Clear selection

Acknowledgment, Waiver and Release of Liability: I hereby confirm the participant is in good health and able to participate in the activity. Also, I have been advised to consult with a licensed physician prior to participation in the activity. I acknowledge the activity may involve both apparent and inherent risks and dangers of bodily injury or death and damage to property. I fully accept and acknowledge the activities may involve risks and I hereby assume all dangers and risks associated with the participant in the activity and will be responsible for the same. I further understand that concussion information is available at www.cdc.gov/concussion. I acknowledge that Baltimore County, Maryland, TALMAR, Inc., and their respective employees, directors, officers, volunteers, members and any other participant, entity, party or person involved in any regard with the Activity or the Activity premises and their respective agents, personal representatives, heirs, employees, contactors, successors and assigns (each an activity representative and collectively the “activity representatives” ), shall not be responsible or liable in any regard or manner for any and all property damaged or bodily injury(including serious physical injury or even death) incurred by participant or any party related thereto, as a result of his/her participation in the activity.I have read, fully understand, and hereby freely sign, approve of, and agree to the terms of this Registration Form. I hereby expressly and forever unconditionally release, discharge, covenant not to sue, waive my rights and remedies, and agree to hold harmless and indemnify the activity representatives from any and all claims, costs, demands, losses, damages, or expense, and from all acts of active and passive negligence or other fault on the part of the activity representatives associated with, in whole or in part, participant’s involvement with the activity. I shall inform TALMAR in writing if any information provided in this Registration Form is incorrect or changes through the course of activity.
*

Yes

Submit

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