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WE'RE HIRING
FRIENDSHIP CIRCLE
A Place To Connect & Belong
MEMBERSHIP FORM
A LITTLE ABOUT YOU
Welcome to Friendship Circle!
We're so glad you're joining or catching back up with us.
What's your full name?
*
What do you like to be called? (preferred or nickname)
BIrthday
Month
Month
Day
Year
Where do you live? (Street Address)
*
(City, State, Zip)
*
Email
*
Best phone number to reach you
*
Single choice
Cellphone
Landline
JUST IN CASE
We likely will never need this, but its important to have on file — who should we call?
Name
*
How do you know each other?
Phone Number
*
SUPPORT & ACCESSIBILITY
A few things that will help us help participants
Is there anything about your health we should know, just so we can be prepared?
Do you use any of these to get around?
Nope, I'm all set
A Cane
A Walker
A Wheelchair
Something else
Would you ever need a hand getting to and from our programs?
*
Yes, most of the time
Sometimes
No, I'm good getting there myself
No, and I actually like offering a ride to others when I can
MEMBERSHIP
Please select one membership option below:
*
Single Membership
$65
Couple/Family Membership
$95
Additional Member's Name
Additional Member's Contact Information
Please Include in my Membership
Mailer - One year of PRINTED PROGRAM NEWSLETTERS sent to my home address
$15
Is this a renewal or new membership?
New Member
Renewing Member
LAST STEP
A Few Things We Need to Ask
PHOTO & MEDIA RELEASE - We love celebrating our community! Occasionally we take photos or videos at programs to share in our newsletter, annual report, or on social media.
*
Yes, it's okay to use photos/videos of me for these purposes
No, please don't include me in photos or videos
EMERGENCY CONTACT CONSENT In the rare case of a medical emergency during a program, we want to be able to act quickly.
*
I give JCC SoCo permission to seek emergency medical care and contact emergency services on my behalf if needed, and to share relevant health information from this form with first responders.
PARTICIPATION & LIABILITY RELEASE - Friendship Circle programs may include physical activity, travel by bus or car, and time in public spaces.
*
I understand these activities carry some inherent risk, and I release JCC SoCo, its staff, and volunteers from liability for injury not caused by their negligence.
Typed Full Name (acting as your signature):
*
What's Next?
How Should We Reach You?
Give me a call
Text me
Email me
Send it in the mail
I would like a personal phone call from a Friendship Circle member to learn more about the program opportunities and/or to ask questions.
Yes
No
Submit
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