Soul Cafe Trainee Registration July-September 2022

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Participant Contact Information

Participant Name*

First Name

Last Name

Date of Birth*

Participant Email*

If participant does not have an email write in Primary Contact's email here

School Attending*

If not attending write NA

List any programs that you have previously participated in at Friendship Circle

Participant Cell Number*

If participant does not have a cell number write the number of your emergency contact

Participant's Address (Where participant lives currently)*

Address Line 1

City

State

ZIP Code

Primary Contact Information

Primary Contact Name*

First Name

Last Name

Primary Contact Email*

Primary Contact Cell Number*

Primary Contact Address*

Address Line 1

City

State

ZIP Code

Relationship Between Primary Contact and Participant*

Secondary Contact Information

Secondary Contact Name*

First Name

Last Name

Secondary Contact Email*

Secondary Contact Cell Number*

Secondary Contact Address*

Address Line 1

City

State

ZIP Code

Relationship Between Secondary Contact and Participant*

Does participant have a legal guardian other than themselves?*

Yes No

Guardianship/Conservatorship

Legal Guardian/Conservator Name*

First Name

Last Name

Relationship to Participant*

Legal Guardian Cell Number*

Legal Guardian Email*

Legal Guardian's Address*

Address Line 1

City

State

ZIP Code

General Information

Is there any additional information that would assist Friendship Circle?*

Yes No

Additional Information*

Emergency Medical Information

Hospital Affiliation*

Medical Insurance Carrier*

Policy Number*

Emergency Contact Name*

First Name

Last Name

Emergency Contact Number*

Emergency Contact Relationship*

Name of Doctor*

First Name

Last Name

Doctor Phone Number*

Name of Secondary Doctor

First Name

Last Name

Secondary Doctor Phone Number

Medical Diagnosis or Condition(s)*

Current Medications*

Allergy Information*

Other Relevant Medical History

Waivers

Medical & Emergency Release

The above participant has my permission to attend Friendship Circle and Soul Studio events. I agree not to hold Friendship Circle liable for any accident, loss or theft that may occur during the course of an event.

I hereby give my permission to the physician indicated above by the Friendship Circle to hospitalize, and/or secure necessary treatment or anesthesia for participant, as named above, in the event that I cannot be reached in an emergency. I hereby give my permission that paramedics may transport participant to the nearest hospital, if necessary. I have indicated any pertinent medical information above. I agree to the terms and conditions of this application

Liability Waiver

I will not hold Friendship Circle liable for any accidents, injuries, damage or fatalities which may occur in transit to/from aforementioned events

I also waive all rights to sue Friendship Circle for any of the above-mentioned incidents which may occur in transit.

BY AGREEING TO THIS WAIVER, I/WE FREELY ACCEPT AND FULLY ASSUME RESPONSIBILITY FOR ALL SUCH DANGERS AND RISKS AND THE POSSIBILITY OF PERSONAL INJURY, DEATH, PROPERTY DAMAGE OR LOSS RESULTING THEREFROM.

IN CONSIDERATION OF UTILIZING THE RELEASEES’ FRIENDSHIP CIRCLE FACILITIES,

I/WE HEREBY AGREE AS FOLLOWS:

1. TO WAIVE ANY AND ALL CLAIMS for personal injury including death, illness, property damage, and negligence that I/we may have against Releasees, their partners, principals, directors, officers, affiliates, agents, employees, contractors, representatives, members, all individuals and entities acting in concert with Releasees and any and all volunteers in any way associated with Releasees.

2. TO RELEASE THE RELEASEES FROM ANY AND ALL LIABILITY for any loss, damage, injury, death, medical or other expense that I/we may suffer or that any other party may suffer as a result of my use of Releasees’ facilities, due to any cause whatsoever.

3. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all loss, damages, costs, expenses, claims, liability and obligation for any property damage or personal injury to any third party resulting from my use of Releasees’ facilities, equipment and machinery, including but not limited to attorney fees and costs.

4. THIS RELEASE OF LIABILITY SHALL BE EFFECTIVE AND BINDING upon my heirs, next of kin, executors, administrators, successors, and assigns in the event of my personal injury including death, illness, and/or property damage.

5. I/WE ADDITIONALLY AGREE not to take unreasonable risks while using supplies, tools, equipment and machinery, and other of Releasees’ activities, including but not limited to attempting skills or tricks that I am not qualified to perform safely or causing any other participant/spectators unreasonable risk of harm. I/we agree to follow all rules set forth by the Releasees with respect to using the equipment and machinery.

I/WE HEREBY CERTIFY THAT I/we am covered by my own medical insurance, and that I/we have read and understand this Release of Liability prior to signing it, and I/we am aware that by signing this Release of Liability I/we am waiving certain legal rights which I/we or my heirs, next of kin, executors, administrators, successors, and assigns may have against the Releasees.

Releasees shall have the right to impose any additional conditions which, in the opinion of the Releasees, will further the intent and legal rights and waivers provided herein.

This liability waiver is made and executed in the State of Michigan and shall be governed by, enforced in and construed in accordance with the laws of the State of Michigan.

I hereby agree to the waivers above:*

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Use your mouse or finger to draw your signature above

Program Registration

Soul Discovery
2 days per week, 2 hours per day
4 days total
$45/day
Dates and times to be determined by trainer and family

Tier 3
2 days per week
11 AM-2 PM
23 days total
$35/day
Tuesday/Thursday

Tier 2
2 days per week
11 AM-2 PM
21 days total
$25/day
Monday/Wednesday

Tier 2
2 days per week
11 AM-2 PM
23 days total
$25/day
Tuesday/Thursday

Tier 1
Expected to do two-weekday sessions and some Sunday sessions
Mon-Thurs 12:00-4:00 PM
Sunday 10:00 AM-4:00 PM
No fee
Shifts will be determined based on the needs of Soul Cafe and the Trainee
Program Selection Field Type: Checkbox*

Soul Discovery

Soul Discovery - 4 Sessions

4 sessions at $45/ea

$ 180.00

Quantity:

Tier 3

Tier 3 Tuesday and Thursday

23 sessions at $35/ea

$ 805.00

Quantity:

Tier 2 Monday/Wednesday

Tier 2 Monday and Wednesday

21 sessions at $25/ea

$ 525.00

Quantity:

Tier 2 Tuesday/Thursday

Tier 2 Tuesday and Thursday

23 sessions at $25/ea

$ 575.00

Quantity:

Tier 1

No fee

FREE

Quantity:

In-Person Total $

Waivers and Policies

I will not hold Friendship Circle liable for any accidents, injuries, damage or fatalities which may occur in transit to/from aforementioned events

I also waive all rights to sue Friendship Circle for any of the above-mentioned incidents which may occur in transit.

BY AGREEING TO THIS WAIVER, I/WE FREELY ACCEPT AND FULLY ASSUME RESPONSIBILITY FOR ALL SUCH DANGERS AND RISKS AND THE POSSIBILITY OF PERSONAL INJURY, DEATH, PROPERTY DAMAGE OR LOSS RESULTING THEREFROM.

IN CONSIDERATION OF UTILIZING THE RELEASEES’ FRIENDSHIP CIRCLE FACILITIES,

I/WE HEREBY AGREE AS FOLLOWS:

5. I/WE ADDITIONALLY AGREE not to take unreasonable risks while using supplies, tools, equipment and machinery, and other of Releasees’ activities, including but not limited to attempting skills or tricks that I am not qualified to perform safely or causing any other participants/spectators unreasonable risk of harm. I/we agree to follow all rules set forth by the Releasees with respect to using the equipment and machinery.

Releasees shall have the right to impose any additional conditions which, in the opinion of the Releasees, will further the intent and legal rights and waivers provided herein.

This liability waiver is made and executed in the State of Michigan and shall be governed by, enforced in and construed in accordance with the laws of the State of Michigan.

I have read and agree to the waivers above

Click Here to refer to our cancellation policy
Click Here to refer to the Soul Studio Participant Agreement. This agreement was signed when initially registering for Soul Studio programming.

Walk4Friendship Discount*

I did not fundraise Walk4Friendship 2021 or raised less than $1,000 New Fundraiser with $1,000 Raised for Walk4Friendship 2021 (10% Discount) I raised $1,800 for Walk4Friendship 2021 (15% Discount) I raised $3,600 for Walk4Friendship 2021 (20% Discount) I raised $5,400 for Walk4Friendship 2021 (25% Discount)

How would you like to pay?*

Credit Card Invoice

Total $

Quantity

Sub Total $

Discount Rate

Discount Amount $

Payment

Billing Name*

First Name

Last Name

Billing Email*

Billing Address*

Address Line 1

City

State

ZIP Code

Credit Card*

CampaignId

Form Name

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