Registration Form - ChabadPlace.org

Child-Participant Information
Full Name*
First NameLast Name
Birth Date*
MonthDayYear
Gender*
MaleFemale

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone*
Area CodePhone Number
School*
Grade*
Friendship Visit Selection
Preferred Day for Friendship Visit*
Ideal Time Frame*
HourMinutes
until
HourMinutes
2nd Choice for Friendship Visit*
Ideal Time Frame*
HourMinutes
until
HourMinutes
Parent's Information
Responsible Party*
MomDad
Father's Name*
First NameLast Name
E-mail*
Cell Phone*
Area CodePhone Number
Occupation*
Mother's Name*
First NameLast Name
E-mail*
Cell Phone*
Area CodePhone Number
Occupation*
Medical & Emergency Information
A. In case of an emergency when neither parent can be reached please provide the name of a person who will assume responsibility for your child.
Full Name*
First NameLast Name
Relation to Child*
Cell Phone*
Area CodePhone Number
B. If parents cannot be reached and emergency medical advice is required, permission is granted to the Friendship Circle staff to contact my child's physician.
Physician's Name*
First NameLast Name
Phone Number*
Area CodePhone Number
C. Additional medical information or comments
Allergies*
Medications*
Dietary Restrictions*
Comments
Parental Agreement
If my child participates in the Friends at Home program, I agree that a parent/guardian will be present in the home to supervise them.*
Consent
I permit my child's photo to be used for publicity purposes*
Consent
Where applicable, I permit my child to be transported by the Friendship Circle to or from activities.*
Consent
I hereby release the Friendship Circle, its providers and administrators from ALL liability resulting from any incident which affects the health, welfare or safety of my child while participating in a Friendship Circle program.*
Consent
Comments
Should be Empty:

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The Friendship Circle

Child-Participant Information

Friendship Visit Selection

Parent's Information

Medical & Emergency Information

Parental Agreement