Adult Registration - friendshipsd.org

Adult's Information
Full Name*

First Name Last Name
Gender
Religion

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date

Month Day Year
E-mail*
Special Need
Synagogue Affiliation
Are you a Legal Caregiver?

YesNo
Legal Caregiver Information
* If Applicable
Full Name

First Name Last Name
Relationship to Participant

MotherFatherLegal Guardian/Other
Phone Number
E-mail
Same Address as Participant's Information

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Occupation
Help Us Get To Know You a Little Better
Does you need supervision and support during bathroom routines? (If yes, please explain)
Describe your strengths and weaknesses in the areas of social, cognitive, physical and communicative domains
Any special fears of which we need to be aware? For example: Water, bright lights, animals etc.
Any personality conditions of which we need to be aware? For example: Shyness, hiding, wandering away, tantrums etc.
Are there any special things you like? For example: Running, jumping drawing, painting, sports, animals, music etc.
What are some things that upset you? For example: Transitions, loud noises, new people etc.
Emergency Medical Information
In case of an emergency, when neither parent can be reached, please provide the name of someone who will take responsibility for your child:
Full Name

First Name Last Name
Relation
Phone Number
Hospital Affiliation
Medical Concerns/Diagnosis
Medications Taken Regularly
Medicinal/Environmental/Pet Allergies
Dietary Restrictions
Medical and Emergency Release
I or authorized representative, I hereby give consent to Friendship Circle that I will attend Friendship Circle events. I agree not to hold Friendship Circle liable for any accident, loss, or theft that may occur during the course of an event. I hereby give my authorization to the physician selected by The Friendship Circle to hospitalize, and/or secure necessary treatment or anesthesia for myself, as named above, in the event that I cannot be reached in an emergency. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the individual named above. I hereby give my permission that paramedics can transport me to the nearest hospital, if necessary. I have indicated any pertinent medical information above.
I agree to the terms and conditions of this application. Additionally, I am agreeing by my signature below.*
I give permission for my photo to be used for publicity purposes (i.e., brochures, newspapers, website, social channels, etc.)
Signature
Full Name*

First Name Last Name
Date*

Month Day Year
Signature*
I would like to receive news and updates by email
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Adult's Information

Legal Caregiver Information

Help Us Get To Know You a Little Better

Emergency Medical Information

Medical and Emergency Release

Signature