Preparing a Demo

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I am Filling this out for: *

Myself

My Child

The participant is looking to participate as a *

Teen Friend (Volunteer)

Child with Disabilities

Adult Volunteer

Young Adult Volunteer (Twenties)

How did you hear about Friendship Circle? *

Why are you interested in joining Friendship Circle? *

Participant Name *

Participant Nickname

Participant Date of Birth (use actual birthdate) *

Participant's Pronouns *

Ethnicity

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Participant Religion

Participant Preferred Language

What experience does the participant have working/interacting with people with disabilities? Do they know someone with disabilities?

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What experience does the participant have working/interacting with people with disabilities? Do they know someone with disabilities?

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Participant Recent Photo *

Participant Address *

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Participant Phone (Cell) - Used for FCVA communication purposes only *

Participant Email - Used for FCVA communication purposes only *

Preferred Method of Communication *

Text

Phone Call

Friendship Circle will use contact information provided only for program and event outreach.

I understand

Participant Age

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School (If Applicable)

Year in School (If Applicable)

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Place of Work (If Applicable)

Job Title (If Applicable)

Marital Status

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Parent/Guardian #1 Name

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Parent/Guardian #1 Address

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Parent/Guardian #1 Phone (Cell)

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Parent/Guardian #1 Email

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Parent/Guardian #1 Place of Work

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Parent/Guardian #1 Job Title

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Parent/Guardian #1 Marital Status

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Add another Parent/Guardian?

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Parent/Guardian #2 Name

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Parent/Guardian #2 Address

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Parent/Guardian #2 Phone (Cell)

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Parent/Guardian #2 Email

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Parent/Guardian #2 Place of Work

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Parent/Guardian #2 Job Title

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Parent/Guardian #2 Marital Status

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Those who participate will end up in event photos without identifying information *

I understand

I give permission for the participant to participate in friendship circle

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Which programs are you interested in participating in? Check all that apply. *

Friends@Home (weekly commitment)

Birthday Circle (monthly commitment)

Community Events (when available)

Inclusive Teen Leadership Board (monthly commitment)

Young Adult Program (Twenties)

Senior Circle (18+)

Do you have a friend that wants to join you for Friends at Home?

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Friends at Home Friend Name

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Friends at Home Friend Age

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What are the participant's hobbies and interests? *

Does the participant have allergies? *

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Participant dietary restrictions *

None

Lactose Intolerant

Vegetarian

Vegan

Gluten Free

Other

Please describe their dietary restrictions

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Does the participant have a disability?

Yes

Please describe the participant's disability or disabilities.

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What is the participant's primary method of communication?

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Are there any behaviors the participant has that we should know about?

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Are there any aggressive behaviors the participant exhibits?

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What is the participant sensitive to? (loud noise, light, animals, strangers, textures, etc.)

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Does the participant have any stimming behaviors; how should they be responded to?

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Does the participant have a mental health condition?

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Please describe their mental health condition.

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Does the participant have a medical condition? (Diabetes, Epilepsy, etc.)

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Please describe their medical health condition.

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Friendship Circle of Virginia's Code of Conduct and Confidentiality Agreement

I agree to follow Friendship Circle of Virginia's Code of Conduct. *

I agree

Signature *common.clear

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