YOUR INFORMATION:

First/ Last Name:

Hebrew Name:  Gender Male Female

Facebook Name:  

Birth Date: Age:

Address:

City:  Zip Code:

Phone:

Cell Phone:

E-mail Address:

School: Grade:

What year will you graduate in?

Principal:

How did you hear about us?

___________________________________________________________________________________

PARENTS INFORMATION

Mother’s Name: Title:

Father’s Name: Title:

Mother’s Cell:   Faher’s Cell:

Parent’s E-mail:

Mother’s Occupation (Optional):

Father’s Occupation (Optional):

PARENTAL PERMISSION

I give my teen permission to volunteer in the Friendship Circle.

I give my teen permission to attend Friendship Circle events.

(Type) Signature of Parent/Guardian:

EMERGENCY INFORMATION

Emergency Contact Name (other than a parent):

Phone: Cell:

Please list any allergies:

Please list any medical conditions that we should be aware of:

___________________________________________________________________________________

I WOULD LIKE TO VOLUNTEER FOR THE FOLLOWING PROGRAMS:

Friends @ Home - When would you like to volunteer at a special child’s home?

(1st Choice) Day: Time:

(2nd Choice) Day: Time:

I would like to volunteer with my friend:

Friends phone number   Friends Email

Judaica Circe……………….….......................................…..…..Tuesdays 5:15-6:45 (girls only)

Sunday Circle/Sunday Trips………………….…………...………........Sundays 12:45 Pm

Winter/Summer Camp

Birthday Club

Holiday Programs

Shabbat Party (monthly program)

 T-YAD (Teen and Young Adult Division, monthly progrom)

_____________________________________________________________________________________

REQUIRED:

I agree to keep all information about my Friendship Circle friend and their family confidential.

I know parents entrust their children to Friendship Circle, and i will try to demonstrate that trust and responsibility by being a positive and responsible role model. 

Once I commit to an event, I agree to attend and give it my all.  In the event that I am unable to volunteer, I will try to find a substitute and I will call the office and my special friend in advance.

I understand that Community Service forms will ONLY be issued for volunteering that is recorded on the web site (www.mitzvahrewards.com)

If someone gets hurt or some other incident occurs while I am volunteering, I will make sure to report it to the Friendship Circle staff. 

Type Signature: Date: