Participant Enrollment 1Applicant2Medical Info3All About Me4 HiddenSubmission ID HiddenDebug Registration is for* Participant Sibling Participant's InfoParticipant's Name* First Last Gender* Male Female Birth Date*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HiddenPhone*While most of our programs are non-sectarian and open to the entire community, we do offer some Jewish religious programs for the Jewish community. Association:* YES, I am Jewish and want to be updated with the Jewish programs. NO, I am not and would like to be updated with the non-sectarian programs. HiddenNote: Participant Photo*Accepted file types: jpg, gif, png, jpeg, Max. file size: 50 MB.Participant Email Address Participant Cell Number Important InfoThe participant requires* Teen volunteer Trained adult aide – There will be an additional cost for the aide per program I will supply my own aide – no additional cost HiddenDoes the participant occasionally exhibit any of the following behaviors? Biting Grabbing Kicking Cursing Hitting Running Other HiddenOther things you would like to tell us about the participantAllergiesDoes applicant have any allergies?* Yes No Applicant is allergic to* Hay Fever Poison Ivy/Oak 3. Insect Stings Food Penicillin Other Drugs Other HiddenMedical HistoryHiddenDoes the applicant have a history of or is prone to any of the following Recent injury, illness or infectious disease Chronic or recurring illness Asthma Frequent Ear Infections Seizure Disorder or Convulsions Heart Defect/Disease Hypertension Bleeding/Clotting Disorders Diabetes Joint problems (knees, ankles) Fractures Frequent Headaches Head Injury Eating Disorder Diarrhea or constipation Frequent Stomachaches Other HiddenPhysical Activities to be limited or restricted while at LifeTown Programs Parent/Guardian InfoResponsible Party* Mother Father Guardian Responsible Party's InfoMother's InfoFather's InfoGuardian's InfoName* First Last Occupation Cell Number*E-mail* Parent’s Status* Married Widowed Divorced Separated HiddenWould you like to receive emails from our FC parent network?* Yes No Other Parent's InfoMother's InfoFather's InfoOther Guardian's InfoName* First Last Occupation* Cell Number*E-mail* Consent and Code of ConductI will promote the creation of a friendship community based on mutual respect and a sense of personal well-being. I will treat others with honor and respect because we are all created in the image of G-d. As a volunteer of Friendship Circle: I understand that Friendship Circle expects me to behave responsibly. I agree to utilize my best judgment and sense of responsibility when spending time with the child with whom I am matched. I understand that the use of a cell phone during a Friendship Circle programs does not promote a healthy friendship and should only be used in case of emergency. I agree to respect the privacy of all participants of the Friendship Circle and to keep personal information confidential. I understand that once I commit to attend a program or event, the Friendship Circle staff and special friends expect me to be there. I agree to attend and give it my best effort. In the event that I cannot attend, I agree to give notice to Friendship Circle staff and the parents of my special friend sufficiently in advance. If someone gets hurt or some other incident occurs while I am volunteering, it is my responsibility to immediately report the occurrence to Friendship Circle staff. I agree to represent the Friendship Circle to the best of my abilities. I have carefully read and agree to abide and be bound by all the rules above as well as any additional rules pertinent to specific events, including the Commitment to Everyone’s Safety and Well Being. I grant Friendship Circle permission to use my name, image, likeness, or recording in connection with any promotional materials including, but not limited to, brochures, advertising, and broadcasts. I agree to volunteer for Friendship Circle. I understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and agree to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct as set forth above as well as any additional rules pertinent to specific events. I understand that this local Friendship Circle is independently owned, operated and controlled. I release LifeTown, Friendship Circle and Chabad of Livingston and its employees, directors, officers, contractors and volunteers from any and all claims or liability arising out of this participation. ALTHOUGH FRIENDSHIP CIRCLE CARES DEEPLY ABOUT THE HEALTH AND WELL BEING OF ALL PARTICIPANTS, VOLUNTEERS, STAFF, AND THEIR FAMILIES, FRIENDSHIP CIRCLE CANNOT GUARANTEE THAT COVID-19 OR ANY OTHER VIRUS OR DISEASE WILL NOT BE CONTRACTED BY FRIENDSHIP CIRCLE PARTICIPANTS, THEIR FAMILIES OR STAFF Volunteer's Commitment to Everyone's Safety and Well-Being Friendship Circle provides very special and unique opportunities for volunteers, special friends and their families to enrich the lives of each other. In doing so, most participants will encounter new and sometimes challenging situations. Thus, it is imperative to set expectations at the beginning so that volunteers, special friends, and parents understand what they can expect. Therefore, volunteers, special friends, and their respective families each certify and agree to the following by signing below that I: Understand that participation in this activity is entirely voluntary and requires everyone to abide by applicable rules and standards of conduct; Understand that I may be in the company of people with various degrees of social, development, and communication challenges. I understand that if there is ever a situation that I feel uncomfortable, it is my right and responsibility to report the occurrence to the Program Director or Group Leader. Understand that photographs can be private and sensitive and should not be shared by all. Understand that if a Friendship Circle Child needs help in the bathroom, it is my job to notify their parent or the Friendship Circle staff and have them guide me in the proper protocol. Do not use or possess any illegal drug, alcohol or controlled substances at any time, including at Friendship Circle events or programs; Do not have any alcohol or tobacco products at Friendship Circle events or programs; Do not bring any weapons, firearms or other dangerous items to any Friendship Circle event or program; Agree to have a background check performed on me, or if I am under 18, a reference check; Understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for me and/or my child to participate in this activity and knowingly and freely assume all such risks; Will not participate in any activity that I believe I and/or my child cannot perform in accordance with the Friendship Circles activities’ instructions or in a safe manner; If I observe any significant hazard during my or my child’s participation in any event or program, I will stop and/or have my child stop participating in the event and inform the Friendship Circle of such hazard immediately; If I am participating in Friends@Home, agree to abide by and perform everything stated in the Handbook in its entirety. Agree Friendship Circle is not responsible for any damages to personal property or injury in which the Friendship Circle had no knowledge of the particular hazard or any activity outside of Friendship Circle sponsored events; Acknowledge that Friendship Circle is an independently owned, operated and controlled local corporation. I Release LifeTown, Friendship Circle and Chabad of Livingston, the directors, board, officers, activity coordinators, and all employees, volunteers, related parties, and contractors from any and all claims or liability arising out of this participation; Agree that in case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities. I hereby give permission to the Friendship Circle-LifeTown administration to take whatever medical measures they deem necessary in the event of a medical emergency. If the volunteer is under the age of 18, the signature of a parent or guardian signature is necessary, please sign below: Consent* I have read and agree to the waiver and code of conduct provided above.SignatureHiddenWill you be sending a caregiver / aide / nurse?* Yes No HiddenIn-Person ProtocolHiddenCode of Conduct Parent/Guardian Signature Actions Edit Delete There are no Code of Conducts. Add Code of Conduct Maximum number of code of conducts reached. Please read and sign the code of conductI allow applicant's photo to be used for any and all Friendship Circle publicity purposes.* Yes No Who is filling out this form?* Mother Father Legal Guardian Hidden* I hereby give permission to the Friendship Circle-LifeTown administration to take whatever medical measures they deem necessary for my child in the event of a medical emergency. Signature*CommentsCommentsThis field is for validation purposes and should be left unchanged. Δ