FCLA Volunteer Application 2017-18

Volunteer Information
Full Name *

Prefix First Name Last Name
Hebrew Name
Your Jewish Name
Gender *

Male Female
Date of Birth *

- Month - Day Year
Date
Email *
example@example.com
Phone Number *

- Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Home Phone *

- Area Code Phone Number
Mobile Phone

- Area Code Phone Number
School Attending *
Grade *
Synagogue Affiliation
Parent/Guardian Status *
Volunteer Lives With:
Parents/Guardian Information
Mother's Name *

First Name Last Name
Mother's Hebrew Name

Home Address (if different than volunteer's)

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

Home Phone (if different than volunteer's

- Area Code Phone Number
Mother's Mobile Phone *

- Area Code Phone Number
Mother's Occupation *
Mother's Place of Employment

Mother's Work Address

Street Address
Street Address Line 2
City	State
Zip Code	Country

Mother's Work Phone

- Area Code Phone Number
Mother's Email *
example@example.com
Synagogue Affiliation (if different than volunteer's)
Father's Name *

First Name Last Name
Father's Hebrew Name

Home Address (if different than volunteer's)

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

Home Phone (if different than volunteer's)

- Area Code Phone Number
Father's Mobile Phone *

- Area Code Phone Number
Father's Occupation
Father's Place of Employment

Father's Work Address

Street Address
Street Address Line 2
City	State
Zip Code	Country

Father's Work Phone

- Area Code Phone Number
Father's Email *
example@example.com
Synagogue Affiliation (if different than volunteer's)
Medical Information
Volunteer's Legal Name *

First Name Last Name
Any medical conditions or allergies? If yes, please list medications and frequency. *
Emergency Contact Name *

First Name Last Name
Emergency Contact Home Phone *

- Area Code Phone Number
Emergency Contact Mobile Phone *

- Area Code Phone Number
Doctor *

First Name Last Name
Doctor's Phone Number *

- Area Code Phone Number
Insurance Information
Insurance Carrier *
Insurance Phone Number *

- Area Code Phone Number
Accident & Trip Declaration
Accident: As the parent/legal guardian of {fullname3}, I authorize any adult acting on behalf of Friendship Circle Los Angeles to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Friendship Circle personnel will try, but are not required, to communicate with me prior to such treatment.

Trips and Outings: I hereby give permission for my child/self, {fullName3}to attend and participate in all trips and outings organized as part of the program by Friendship Circle.
Parent/Guardian Signature (or volunteer over 18 years old) *
Parental Consent and Volunteer Agreement

For Volunteers Under 18
- I give my teen permission to volunteer at all Friendship Circle events.
- I understand that community service or fellowship points will only be issued to my teen for hours submitted on a monthly basis, on our website or app.
- I understand that community service hours will be submitted to your school per your request, with a 5-7 business day process time.
PARENTAL CONSENT: Parent/Guardian Signature *
VOLUNTEER AGREEMENT: Volunteer Signature *
Release to Perform Background Check

For Volunteers 18 and Above
I hereby grant the Friendship Circle of Los Angeles permission to perform a background check on me as required by the law. This information will be kept confidential.
Social Security Number
BACKGROUND CHECK CONSENT: Signature
2017-18 Program Lineup

Choose which programs you are interested in, and our coordinators will be in touch to get you started!
Friends at Home Program (please specify which days and times would work for you):
Recurring Programs

Hebrew School - Sundays from 9:00am-11:00am Sunday Circle (Girl Volunteers Only) - 15 Sundays a year from 10:30am-1:00pm Birthday Bash - 3 Sundays a year from 11:15am-12:15am Basketball Club (Boy Volunteers Only) - Wednesdays from 6:30pm-8:00pm
Special Events

Winter Camp - December 24-29, 2017 Summer Camp - August 5-10, 2018 Holiday Programs - Rosh Hashana, Sukkot, Chanukah, Tu B'Shevat, Purim and Passover Saturday Night Fun - December 2, 2017
Commitment to Safety & Well-Being
Friendship Circle provides very special and unique opportunities for volunteers, special friends and their families to enrich the lives of each other. In doing so, participants might encounter new and sometimes challenging situations. Thus, it is imperative to set expectations at the beginning so that volunteers, special friends, and parents understand what they can expect. Therefore, volunteers and a parent must each certify and agree by signing below that they:
- Understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct;
- Understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for me and/or my child to participate in this activity;
- Acknowledge the risk of injury from the activities involved in the Friendship Circle events or program and knowingly and freely assume all such risks;
- Will not allow me/my child to participate in any activity that you believe you and/or your child cannot perform in accordance with the Friendship Circles activities’ instructions or in a safe manner;
- If you observe any significant hazard during your participation in any Event, you will stop participating in the event and inform the Friendship Circle of such hazard immediately;
- Release Friendship Circle, the directors, board, officers, activity coordinators, and all employees, volunteers, related parties, and other organizations associated with the activity from any and all claims or liability arising out of this participation provided that care was taken to insure safety;
- In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me/my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.
- I grant the Friendship Circle permission to use my or my child’s name, image, likeness or recording in connection with any promotional materials including, but not limited to, brochures, advertising, and broadcasts.
Volunteer Code of Conduct
I will promote the creation of a friendship community based on mutual respect and a sense of personal well-being. I will treat others with honor and respect because we are all created in the image of G-d.

As a volunteer of Friendship Circle:
- I understand that Friendship Circle expects me to behave responsibly. I agree to utilize my best judgment
- and sense of responsibility when spending time with the child with whom I am matched.
- I understand that the use of a cell phone while volunteering does not promote a healthy friendship and should only be used in case of emergency.
- Friends @ Home: In the event that I am unable to volunteer during my scheduled visit, I will try to find another day to substitute and I will notify the parents of my special friend, and my Friends @ Home coordinator at least 48 hours in advance.
- I agree to respect the privacy of all participants of the Friendship Circle and to keep personal information confidential.
- I understand that once I commit to attend an event, the Friendship Circle staff and special friends expect me to be there. I agree to attend and give it my best effort. In the event that I cannot attend, I agree to give notice to Friendship Circle staff, at least 48 hours in advance.
- If someone gets hurt or some other incident occurs while I am volunteering, it is my responsibility to immediately report the occurrence to Friendship Circle staff.
- I agree to represent the Friendship Circle to the best of my abilities.
- I have carefully read and agree to abide and be bound by all additional rules and policies in the Friendship Circle Handbooks and any additional rules pertinent to specific events.
- I agree to volunteer for Friendship Circle. I grant Friendship Circle permission to use my name, image, likeness, or recording in connection with any promotional materials including, but not limited to, brochures, advertising, and broadcasts. I understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and agree to participate in this activity. I also 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 the Friendship Circle Handbook, as it may be modified from time to time. I understand that this local Friendship Circle is independently owned, operated and controlled. I release the Friendship Circle and its employees, directors, officers, and volunteers as well as its affiliates and all other organizations associated with Friendship Circle from any and all claims or liability arising out of this participation.
SAFETY & CODE OF CONDUCT AGREEMENTS: Parent/Guardian Signature *
SAFETY & CODE OF CONDUCT AGREEMENTS: Volunteer Signature *
Personality & Preferences

In an effort to match you with a child that is most suitable for you, please complete the questions below. This is not a test – just our way of getting to know you better!
Why have you chosen to volunteer at the Friendship Circle as opposed to other community service centers? *
Please tell us more about your personality. For example, What is your greatest strength or talent? What are your strongest character traits? *
What do you value most in a friendship that you are looking forward to sharing with a special friend? *
What hobbies or extra-curricular activities do you enjoy? *
Do you have a talent or hobby you might like to share with the children? *
What area do you live in? *
How far can you/or your parent drive to a child’s house?
What age children are you interested in working with? *
On a scale of 1-10, 1 being the least and 10 being the most, how challenging of a kid are you comfortable with? *
References (Required)
We require two reference forms to be submitted for your application to be complete. It can be a Rabbi, teacher or someone that is familiar with how you work with children. Simply direct them to the link below, or print the forms for them and email them to us.

Reference Forms
Sponsor A Child (Optional)

We offer over 18 social, recreational, and educational programs for the children throughout the year. Please join us in making the FC experience possible for a child who has special needs!
Make a Donation to Friendship Circle

USD
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Volunteer Information

Parents/Guardian Information

Medical Information

Insurance Information

Accident & Trip Declaration

Parental Consent and Volunteer Agreement

Release to Perform Background Check

2017-18 Program Lineup

Commitment to Safety & Well-Being

Volunteer Code of Conduct

Personality & Preferences

References (Required)

Sponsor A Child (Optional)