Child/Teen Participant Registration Form

Adult Participant Registration Form

We request a $175 annual membership fee. You may remit payment by credit card below or mail a check payable to Circle of Friends. (The form may be submitted without payment)
"All information provided on this form will be used by Circle of Friends for the purposes of the organization and will be viewed by employees, officers, volunteers and agents of the Circle of Friends and may be disclosed by any of them in furtherance of the purposes of the organization and or the program or event in which the participant or volunteer is registering. For more information on the treatment of personal information collected by Circle of Friends please see our privacy statement which is available here: View our Privacy Policy Here
Participant's Name*

First NameLast Name
Hebrew Name
if applicable
Age*
Birth Date*

MonthDayYear
E-mail for communication*
Participant Cell Phone Number

Area CodePhone Number
Is the address below a Group Home?*

YesNo
Home/Group Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
School/Workplace
If applicable
Group Home Supervisor Name
if applicable
Group Home Supervisor Phone Number

Area CodePhone Number
Family Information
Parent's Address if different than above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Name

First NameLast Name
Hebrew Name
if applicable
Mother's Cell Phone

Area CodePhone Number
Mother's E-mail
Father's Name

First NameLast Name
Hebrew Name
if applicable
Father's E-mail
Father's Cell Phone

Area CodePhone Number
Names and ages of siblings
Program Selection

Select the program/s you would like to participate in.

Rows	Programs
Home with Friends
Young Adult Circle
Adult Circle
Life Skills
Training/Employment in our Bakery

T-Shirt Size

X-SmallSmallMediumLarge
Home with Friends

It is our pleasure to provide you with our Home With Friends program, however it is necessary for a guardian to assume responsibility to oversee activities shared together and be home during the home visits.
What day you like the volunteers to come visit you at your home?

Day of the weekTime
2nd choice, day of the week

2nd choice of dayTime
General Information
"All information provided on this form will be used by Circle of Friends for the purposes of the organization and will be viewed by employees, officers, volunteers and agents of the Circle of Friends and may be disclosed by any of them in furtherance of the purposes of the organization and or the program or event in which the participant or volunteer is registering. For more information on the treatment of personal information collected by Circle of Friends please see our privacy statement which is available here: View our Privacy Policy Here
Areas of Challenge/Diagnosis
Mode of Communication

VerbalSignWrittenComputerAugmentativeOther
What types of activities do they enjoy?
Behavior & Skills
Events/circumstances that trigger behavior issues
Describe any sensory issues they may have
Other Information regarding social/behavioral skills that we should be aware of
Medical Information
"All information provided on this form will be used by Circle of Friends for the purposes of the organization and will be viewed by employees, officers, volunteers and agents of the Circle of Friends and may be disclosed by any of them in furtherance of the purposes of the organization and or the program or event in which the participant or volunteer is registering. For more information on the treatment of personal information collected by Circle of Friends please see our privacy statement which is available here: View our Privacy Policy Here
Any special medical circumstances
Seizures

YesNo
Type & Frequency
Allergies (list)
Medications
Restrictions
Photo Release

“I as the parent or legal guardian of the participant, hereby expressly agree, without any right to inspect or approve finished product or use of images, to permit:

1. The taking, use, reuse, publishing and republishing or photographic images of me, the participant / or my child including images of me the participant/ or my child may be included in whole or in part, or composite or distorted in character or form without restriction as to changes or alterations from time to time, in conjunction with me the particpant /my child’s own or fictitious name, or reproductions of such photographs in color or otherwise, made through any medium, and in any and all media nor or hereafter known, including the internet, for art, advertising, trade or any other purpose whatsoever;

2. The Use of any published content/matter in conjunction with such photographs; and

3. The digital compositing, or distortion of the images, including without limitation any changes or alterations as to color, size, shape, perspective, context, foreground or background;

all in the furtherance of the mission of the Circle of Friends (including advocacy or lobbying).

I hereby expressly assume responsibility for and fully release and hold harmless, Circle of Friends, its officers, employees, volunteers and agents, including any photographer engaged by any of them, from and against any claims for damage or loss relating to any of the forgoing.”
Signature *

Clear
Participation Assumption of Risk Waiver & Release of Liability
In consideration of being allowed to participate in any way in the programs, related events and activities of the Circle of Friends. (including the “Home with Friends” program and events sponsored by any group associated with the Circle of Friends (including Beth Israel Chabad, Norwalk, CT) the undersigned, acknowledge and agree that:

1.     The risk of injury from the activities involved in any event or program is significant, including the potential for permanent paralysis and death. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM NEGLIGENCE OF THE RELEASEES or others and I assume full responsibility for my participation.

2.     I willingly agree to comply with rules and other terms and conditions for participation (“Rules”). If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of Circle of Friends immediately. I understand that any failure to follow Rules may end my participation in the program or event.

3.     I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Circle of Friends, its officers, volunteers, agents and/or any Beth Israel Chabad officers, employees, volunteers or agents, other participants and, if applicable, owners and lessors of any premises used to conduct the event or to transport me to or from the event (RELEASEES), from any and all claims, demands, losses, and liability (including attorney’s fees and costs) arising out of or related to any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

4.     In the event of an injury requiring medical attention, I hereby grant permission to the officers, volunteers and agents at the program or event to seek emergency medical attention without further consent from me or my parent(s) or guardian and I understand and agree that I shall be responsible for all associated medical costs and related expenses whether or not covered by my own medical insurance.

I/We have read and understand this Assumption of Risk, Waiver and Release of Liability prior to signing it, and I/we am aware that by signing this Assumption of Risk, Waiver and Release of Liability I/we am waiving Substantial legal rights which I/we or my heirs, next of kin, executors, administrators, successors, and assigns may have against the Releasees. This liability waiver is made and executed in the State of Connecticut and shall be governed by, enforced in and construed in accordance with the laws of the State of Connecticut. I/we acknowledge that in executing this Assumption of Risk, Waiver and Release of Liability, I/we are not relying on any inducements, promises, or representations made by the Releasees.
Signature *

Clear
Date*

MonthDayYear
Date

Membership Fee $

USDMembership fee $175

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Adult Participant Registration Form

Family Information

Program Selection

Home with Friends

General Information

Behavior & Skills

Medical Information

Participation Assumption of Risk Waiver & Release of Liability