IMPORTANT INFORMATION Thank you for your volunteering at the Friendship Circle.If you would like to start volunteering, please fill out our forms. An initial interview must be arranged. VOLUNTEER INFORMATION Full Name* First Name Last Name Birth Date* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Gender Male Female Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Home Phone Number* Area Code Phone Number Cell Phone Number* Area Code Phone Number E-mail* School* Graduating Year (HS)* Synagogue Affiliation* How can we contact you? Home Phone Cell Phone Email Facebook Text Message FAMILY INFORMATION Parent’s Address:* Both parents have the same address as above Father has a different address than above Mother has a different address than above Address (if different from above): Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Father's Name First Name Last Name Father's Cell Number Area Code Phone Number Father's E-mail Employer Work Phone Area Code Phone Number Mother's Name First Name Last Name Mother's Cell Number Area Code Phone Number Mother's E-mail Employer Work Phone Area Code Phone Number VOLUNTEER MEDICAL INFORMATION, EMERGENCY CONTACT INFORMATION & WAIVERS *If you are under 18, you must have a parent fill out the next sections. Name of parent filling out the information below: Does volunteer have any allergies* Yes No If yes, please list allergies: List any medication volunteer takes on a regular basis Please list any activities volunteer will not be able to participate in due to a limitation or medical condition. Please list any additional concerns or information our staff should be aware of to ensure the volunteers safety Emergency contact (other then parent) Name Relationship Emergency Contact Phone Number Area Code Phone Number Emergency Contact Cell Number Area Code Phone Number WAIVERS (Please initial each) Transportation: I hereby give permission to the Friendship Circle to transport my child to and from any excursion while my child is in their care. Transportation II: I will not hold Friendship Circle liable for any accidents, injuries, damage or fatalities which may occur in transit to/from the aforementioned event. Liability: I waive all rights to sue the aforementioned organizations for any of the above mentioned incidents which may occur in transit or at Friendship Circle Publicity: I agree that my childs photo many be used for any and all Friendship Circle publicity purposes Please complete the application by checking off the box below: In the event I am unable to attend, I will try to find a replacement and notify the Friendship Circle prior to the event. Volunteer’s Signature: If the participant is under the age of 18 or a guardian signature is necessary, please sign below* Date:* Full Name of Parent/Guardian* Date: FRIENDSHIP CIRCLE’S CODE OF CONDUCT I 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: • Volunteers MUST come 15 minutes prior to when their program begins in order to be ready and waiting for their buddy. • Parents should be told encouraging things about their children. Any negative feedback should be told to staff and NOT parents. • Feedback should be emailed to [email protected]. • Volunteer hours must be logged on our FCConnect App no later then a month after the program in order for it to be accepted. Absolutely no volunteer hour forms will be signed without them being logged on the app beforehand. • In the event that someone gets hurt or some other detrimental incident occurs while I am volunteering, I will report the occurrence to the Friendship Circle Staff. • I understand that parents are relying on the Friendship Circle to match their child with a responsible teenager. I agree to utilize my best judgment and sense of responsibility when spending time with the child I am matched with. • I understand that the use of a cell phone during volunteering 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 an event, the Friendship Circle staff and special friends are relying on 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, at least 48 hours in advance. • I agree to represent the Friendship Circle to the best of my abilities. • I have carefully read agree to abide and be bound by all additional rules and policies in the Friendship Circle Handbooks and any additional rules pertinent to specific events. I agree to volunteer for Friendship Circle. 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 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 in the Friendship Circle Handbook, as it may be modified from time to time. I understand that this local Friendship Circle is an independent owned, operated and controlled. I release the Friendship Circle and its employees, directors, officers and volunteers as well as all other organizations associated with Friendship Circle from any and all claims or liability arising out of this participation. Full name of volunteer:* Volunteer’s Signature:* Date* Parent/ Guardian’s Name* Date* TEEN VOLUNTEER PROGRAM SIGN UP FRIENDS @ HOME Flexible times and dates Have you ever participated in friends @ home in the past? Yes No If so, what was the name of the child/family? Would you like to continue with this family? Yes No What days are you available to do Friends @ Home? Sunday Monday Tuesday Wednesday Thursday Friday What time works best for you? Do you have your Drivers License? Yes No If no, is a parent available to drive? Yes No Do you have a friend you would like to volunteer with? Yes No Friend's Name Friend's Phone Number 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 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; 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; 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. Release Friendship Circle, the directors, board, officers, activity coordinators, and all employees, volunteers, related parties, and other organizations associated with the activity 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. Full Name of Volunteer* Volunteer’s Signature:* Date* If the volunteer is under the age of 18, the signature of a parent or guardian signature is necessary, please sign below: Full Name of Parent/Guardian Parent/Guardian Signature Date Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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