Personal Information 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 2022 2021 2020 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 Prefer not to say 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 Eswatini 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 Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island 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 Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga 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* Area Code Phone Number Cell Phone Area Code Phone Number E-mail* Are you a returning applicant? Yes No School/Occupation* Grade I consider myself* Quiet Average Loud Preferred method of contact* Text E-mail Additional Information Mother's Name* Mother's Cell Phone* Area Code Phone Number Mother's E-mail* Father's Name First Name Last Name Father's Cell Phone Area Code Phone Number Father's E-mail Medical Information Emergency Contact Name* Emergency Contact's Number* Area Code Phone Number Please list any allergies Please list any medical conditions we should be aware of Parental Consent (18 years old and younger) I give my teen permission to volunteer in The New York Friendship Circle @ The Chai Center. Permission to volunteer* Yes No I understand that Friendship Circle events may be live streamed and photos may be taken. I understand my child’s likeness may be used in print or digital media with no names. Names will not be used unless unless express permission is given to use my or my child’s name. Permission for use of my child's likeness* Yes No Signature of Parent* Please initial your consent. I understand that my initial is legally binding as a print signature. Volunteer Agreement I understand my commitement to the Friendship Circle programs and will honor my responsibility. I agree to keep all information about my circle friend/s and their family/ies confidential. I understand that consistency is needed to form friendships. If I sign up for a weekly program, I will do my best to attend all scheduled program dates within the session for which I have signed up. If I can not attend it is my responsibility to contact the office immediately and find another volunteer to take my place. If I have signed up for Friends at Home and can not make my scheduled visit any week, I will call my friend and find another day to have our scheduled visit. Upon receiving email or text correspondence from the Friendship Circle, I commit to respond within 48 hours. I would liked to be matched up for the Friends at Home program Check here I am interested in the following programs: Bowling Arts & Crafts Sports Karaoke Dance Community Service Chorus Theater Yoga & Mindfulness Cooking Virtual Classes I agree to the volunteer agreement* Yes No Signature of Volunteer* I understand that my initial is legally binding as my printed signature. How did you hear about The Friendship Circle? Optional Community Service Fee: $25 This fee will help support our 2021-2022 programs to make them as amazing and special as possible. That being said, we want our programs to remain accessible to everyone. If you have any questions or concerns, please contact [email protected]nyfriendshipcircle.com . Community Service Fee Optional Yes, I would like to contribute $25 No, I will not be contributing at this time Payment Paypal has been selected. Payment will take place on the next page. 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