"ESMACH" Girls Summer Circle ( * designates required fields)

 

FIRST NAME *: LAST NAME *:
GENDER: MALE FEMALE AGE:
DATE OF BIRTH *: SCHOOL:
ADDRESS *: CITY *:
STATE: ZIP CODE:
HOME PHONE *: CELL PHONE *:
E-MAIL ADDRESS *:

YES, I recieve text messages.

** Please provide a current-working email, as we send out event invitations and information primarily through email.

       
 

PARENTS' INFORMATION

   
FATHER'S NAME: MOTHER'S NAME:
FATHER'S MOBILE: MOTHER'S MOBILE:
FATHER'S E-MAIL: MOTHER'S E-MAIL:

MEDICAL EMERGENCIES

A. Emergency contact, in case neither parent can be reached.

NAME *:

RELATIONSHIP TO CHILD *:
HOME PHONE *: CELLPHONE *:
ADDRESS: CITY/STATE/ZIP:
 
B. If parent cannot be reached and emergency medical advice is needed, permission is given to the Valley Friendship Circle staff to phone my child's doctor.
DOCTOR *:

PHONE *:

ADDRESS: CITY/STATE/ZIP:
DOCTOR'S HOSPITAL AFFILIATION:
 
C. In case of medical emergency requiring immediate care, I authorize the Valley Friendship Circle staff and/or paramedics to take my child to the nearest hospital to receive medical care.
Health insurance NAME: NUMBER:

D. Food allergies:

E. Additional medical information or comments:

I permit my child's photos to be used for publicity purposes to assist the Valley Friendship Circle.

As a Parent of a special needs child of Friendship Circle:

1) I understand that as part of the "ESMACH" Summer Circle program, the Valley Friendship Circle will match my child with one teenage volunteer.
 
2) I agree to respect the privacy of all participants of the VFC and to keep personal information confidential.
 
3) I agree that the parent/guardian takes full responsibility for everything that transpires during the visit and exempts the Valley Friendship Circle from any responsibility
4) I give my child permission to participate in the Valley Friendship Circle. I 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 above, as it may be modified from time to time. I understand that this local Valley Friendship Circle is an independent owned, operated and controlled
5) I, myself and on behalf of my child, release the Valley Friendship Circle and its employees, directors, officers and volunteers as well as all other organizations associated with the VFC from any and all claims or liability arising out of this participation.

Parent/Guardian’s Signature: Date:

 

All donations are in US dollars and are tax-deductible

For my daughter's participation in the VFC Girls Summer Circle

July 11-15, 2016

$25 Registration Fee

Summer Circle is Free! (Nominal fee for certain trips/activities)

PAYMENT INFO

Last Name

First Name

Address

City/State/Zip

PAYMENT METHOD

Name on card

Card Number

Exp. Date

Sec Code


Payment total