DKJA -

1Volunteer Information

2About Me

3Parent/Guardian Information

4Program Registration

5Medical & Emergency Information

6Consent

Volunteer Registration

We warmly invite you to complete this contact form, enabling us to stay in touch and welcome you to join Friendship House as a valued volunteer.

Name *

First

Last

Gender *

Male
Female

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

Email *

Which school do you attend? *

Grade *

8th Grade
Freshman
Sophomore
Junior
Senior

Religion? *

Are you affiliated with any Temple? *

Please note which Temple you are affiliated with.

Best method of contact: *

Call
Text
Email

References

Please list 2 non-family references:

Name 1 *

First

Last

Phone Number *

Connection: *

Name 2

First

Last

Phone Number

Connection:

Why are you interested in participating in Friendship House?

What does friendship mean to you? What does inclusion mean to you?

What do you hope to get out of your experience at Friendship House? What are your expectations?

Please tell us more about your personality. For example, What is your greatest strength or talent? What are your strongest character traits?

What do you enjoy doing the most?

Are you interested in a leadership position? (Only available for Juniors and Seniors who are full-time volunteers) *

Volunteer leadership has the opportunity to impact our community on a greater scale and includes the following requirements; recruiting other volunteers at your school, creating exclusive volunteer events, and promoting Friendship House in your community and on social media.

Are you over 18? *

Parent Information

Mother's Name *

First

Last

Mother's Cell *

Mother's Email *

Occupation:

Father's Name *

First

Last

Father's Cell *

Father's Email *

Occupation

Marital Satus *

Married
Separated
Divorced
Other

Second Address

Address Line 1

Address Line 2

City

State

Zip Code

Programs

I want to volunteer: *

Full-Time
Part-Time

Full-Time: Can volunteer up to a few hours a week or volunteer in more than one program. Part-Time: 1 hour a week.

Do you have a friend you would like to volunteer with?

Please note your friend will be required to register as well.

Friends Name *

First

Last

Do you have your own transportation? *

Communication

It is essential to communicate in a timely manner, and we thank you in advance for all you do and the time you give to make it all possible. Friendship House will send out program updates and relevant info via text (as well as email). Please save 561-788-4388 in your contacts as Friendship House to ensure you don't miss any program updates.

Medical Information

Emergency Contact *

First

Last

*In case of emergency, when neither parent can be reached, please provide the name of a person who will assume responsibility for volunteer.

Relationship to Member *

Emergency Contact Phone *

Emergency Care *

In case of emergency requiring emegency care, I authorize the paramedics to take member to the nearest hospital, if necessary.

Health Insurance Provider

Health Insurance ID Number

Physician Name

First

Last

Physician Phone

Additional Medical Information

Any additional medical information that would be helpful for us to know in case of emergency

Allergies & Dietary Restrictions:

I hereby give my child/self permission to participate in Friendship House programs *

I permit my child/self's photo to be used for promotional purposes *

Yes, I do.

Please note Friendship House will not tag or use your name unless we reach out to you first and receive permission.

Pickup Permission

First

Last

I hereby give permission to the following person to pick up my child from any Friendship House activity.

Pickup Permission Relationship to Member

Pickup Phone

Liability Waiver *

First

Last

By typing my name above, I release Friendship House Corporation, its providers, and administrators from all liability for any incidence which affect the health, welfare, or safety of my child/self while participating in Friendship House Programs.

Signature Date & Time *

Date

Time

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Making a difference in the lives of youth with special needs!

Volunteer Registration

References

Parent Information

Programs

Communication

Medical Information

Friendship House

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