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Family Registration
Shabbat Walk Family Registration Form
FAMILY DETAILS
Title:
Mr
Master
Mrs
Ms
Miss
First name:
Surname:
Address:
Postcode:
Mobile:
Landline:
Email:
How did you hear about Shabbat Walk?
Is this your first contact with Shabbat Walk?
Yes
No
SPOUSE/PARTNER (IF APPLICABLE)
Title:
Mr
Master
Mrs
Ms
Miss
First name:
Surname:
EMERGENCY CONTACT
Name:
Phone number:
Relationship:
Email:
REFERENCES
Due to safeguarding regulations, we will be contacting your Rabbi as a reference
Name of rabbi that knows you best:
Tel:
Shul or Congregation you belong to:
FAMILY MEMBERS IN HOUSEHOLD
Child:
Date of Birth:
Age:
School:
Child:
Date of Birth:
Age:
School:
Add child
Remove last child
EMPLOYMENT AND HOUSING
Occupation:
Full Time/Part Time:
Select
Full Time
Part Time
NA
If your spouse is employed, please state Occupation:
If your spouse is employed, please state Full Time/Part Time:
Select
Full Time
Part Time
NA
Type of housing:
Select
Privately owned
Privately rented
Public housing
Other
ASSISTANCE BY OTHER ORGANISATIONS / AGENCIES
Are you currently being assisted by any other agencies (communal, local authority etc)?
If so, what help are you receiving?
Are you receiving benefits? If yes please elaborate.
Yes
No
MEDICAL
Are there any factors (i.e. medical, accessibility issues) relevant to you or a family member?
ASSISTANCE REQUESTED
Why are you requesting our assistance :
Select
Special needs/ additional needs
Mental health
Single parent
Pre and post birth complications
Financial difficulties
Extenuating circumstances
Details
What assistance would you benefit from?
Playing with Children
Taking out special needs child
Homework Help
Supper time
Holding Baby
Visiting Elderly
Other