Sign-me Up! - VILLAGE CHABAD

Your Information

First Name:*

Last Name:*

Age:*

Month

Day

Year

Date of Birth:*

19

Address:*

City:*

Postal Code:*

Telephone:*

Cell phone:

Email:*

School:*

Grade:*

I consider myself:*

Additional Information

Mother's Name:*

Title:

Mother's Cellphone:

E-mail:

Father's Name:*

Title:

Father's Cellphone:

E-mail:

Religion:*

I understand that to receive a signature on a Community Service form I must send in a weekly email about my visits.

Medical Information

Emergency Contact Name (other than a parent):*

Phone:*

Relationship:*

Cellphone:

Please list any allergies:*

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

Parental Consent

This section must be approved by a parent before proceeding to the completion of the form.

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

I give my teen permission to attend Friendship Circle trips.

I agree that my teen’s photos may be used for any and all Friendship Circle publicity purposes.

I would like to volunteer for:

Friends @ Home


When would you like to volunteer at a special needs child’s home?
1st choice
Day of the week:			Time:

2nd choice
Day of the week:			Time:

Do you have a friend with whom you'd like to volunteer? Yes No
If yes please provide your friend’s name:
Are your parents available to drive you to or from a child’s home? Yes No

	Volunteer Opportunities
	Friends at Home
	Bowling League
	Community Adventures
	Get Moving
	You are what you Eat
	I have other talents that I would like to share with the children
			Please specify:

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

In the event that I am unable to volunteer I will try to find another day to substitute and I will call my special friend in advance.

In the event that I am unable to attend Bowling League I will try to find a substitute volunteer and I will call the office in advance.

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