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:

Add child Remove last child

EMPLOYMENT AND HOUSING Occupation:

Full Time/Part Time:

If your spouse is employed, please state Occupation:

If your spouse is employed, please state Full Time/Part Time:

Type of housing:

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 :

Details

What assistance would you benefit from?
Playing with Children
Taking out child with special needs
Homework Help
Supper time
Holding Baby
Visiting Elderly
Other