Happy Bellies Program

1
Parent's Name* This field is required.
First Name
Last Name
2
E-mail* This field is required.
3
Phone Number* This field is required.
Area Code
Phone Number
4
How many people are in your household?* This field is required.
5
How did you hear about the Happy Bellies Program* This field is required.
6
Prefered method of contact?* This field is required.
Email
Phone
Either
7
Participant's Name* This field is required.Complete all fields.
Enter First and Last Name
Enter Date of Birth 10/15/2015
Please Select
Please Select
Child 18 or
Senior
Disabled
Adult
Select One
8
Participant's NameComplete all fields.
Enter First and Last Name
Enter Date of Birth 10/15/2015
Please Select
Please Select
Child 18 or under
Parent
Senior
Disabled
Adult
Select One
9
Participant's NameComplete all fields.
Enter First and Last Name
Enter Date of Birth 10/15/2015
Please Select
Please Select
Child 18 or under
Parent
Senior
Disabled
Select One
10
Participant's NameComplete all fields.
Enter First and Last Name
Enter Date of Birth 10/15/2015
Please Select
Please Select
Child 18 or under
Parent
Senior
Disabled
Select One
11
Participant's NameComplete all fields.
Enter First and Last Name
Enter Date of Birth 10/15/2015
Please Select
Please Select
Child 18 or under
Parent
Senior
Disabled
Select One
12
Participant's NameComplete all fields.
Enter First and Last Name
Enter Date of Birth 10/15/2015
Please Select
Please Select
Child 18 or under
Parent
Senior
Disabled
Select One
13
Participant's NameComplete all fields.
Enter First and Last Name
Enter Date of Birth 10/15/2015
Please Select
Please Select
Child 18 or under
Parent
Senior
Disabled
Select One
14
Participant's NameComplete all fields.
Enter First and Last Name
Enter Date of Birth 10/15/2015
Please Select
Please Select
Child 18 or under
Parent
Senior
Disabled
Select one
15
Meal Pick-up Instructions* This field is required.Meals are served between the hours of 3:30 pm - 6:30 pm. We DO NOT HAVE PUBLIC RESTROOMS. Please join the line on Eunice Drive and wait for our parking lot attendants to bring you onto the lot. PLEASE DO NOT BLOCK RESIDENTS DRIVEWAYS. We are serving hundreds of meals therefore, cooked meals are provided until we run out. Everyone will receive cooked, and/or heat and eat meals daily. NO CONTACT POLICY STRICTLY ENFORCED! Remain in your car and we will deliver your meals to you.
Tuesday & Thursday
16
Add me to your mail list
Yes please
17
Liability Waiver* This field is required.I agree to hold harmless and release Club Xhell Incorporated, dba Club Xhell Youth Life Center, its Board of Directors, Affiliates, Staff and the Happy Bellies Program of any liability, accidents, or incidents that could potentially happen while participating in the Happy Bellies Program, or on the property thereof. I have enrolled my child(ren) and/or myself and give my permission to participate in the Happy Bellies meal program. I further indemnify and release Club Xhell Incorporated, dba Club Xhell Youth Life Center, its Board of Directors, Affiliates, Staff and the Happy Bellies Program from liability and hold harmless should any sickness, cross contamination or any symptoms of illness of any kind, or infection related to the COVID-19 virus emerges due to direct or indirect contact with Club Xhell Youth Life Center staff, or volunteers during or after services rendered. I, the electronically undersigned, take full responsibility and authorize the child(ren) and all who are listed on this form as a participants, to receive and accept Club Xhell Youth Life Center's act of benevolence at my own risk.
I have read and and agree
18
Electronic Signature* This field is required.Your electronic signature represents that you have the legal authority and/or consent to enroll the above participants in this program.
Type your first and last name
Should be Empty: