Registration Form - ChabadPlace.org

Child-Participant Information
Full Name*

First Name Last Name
Birth Date*

Month Day Year
Gender*

Male Female

Address*

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

Home Phone*

Area Code Phone Number
School*
Grade*
Friendship Visit Selection
Preferred Day for Friendship Visit*
Ideal Time Frame*

Hour Minutes
until
Hour Minutes
2nd Choice for Friendship Visit*
Ideal Time Frame*

Hour Minutes
until
Hour Minutes
Parent's Information
Responsible Party*

Mom Dad
Father's Name*

First Name Last Name
E-mail*
Cell Phone*

Area Code Phone Number
Occupation*
Mother's Name*

First Name Last Name
E-mail*
Cell Phone*

Area Code Phone 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 Name Last Name
Relation to Child*
Cell Phone*

Area Code Phone 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 Name Last Name
Phone Number*

Area Code Phone 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