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Book Club Member Enrollment Form
Email address *
First name *
Your answer
Last name *
Your answer
Date of birth *
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Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone *
Your answer
Email
Your answer
How do you generally travel to places? (i.e. bus, walk, taxi, someone drives me, I drive, etc.) *
Required
What days of the week can you participate in a one-hour book club? Check any days you are available each week. Your club will meet one day each week.
What time of the day would you like to meet for book club?
Are there things you shouldn’t eat or drink due to allergies or medical issues? If yes, please list the items
Your answer
Do you have any health issues (i.e. seizures) that we should know about? If so, please describe: (If you have a medical condition that may require immediate attention, your staff, parent, guardian, or the person who brought you to book club must remain on the premises during the meeting) *
Your answer
Emergency Contact Person *
Your answer
Relationship to that person
Your answer
Emergency contact phone number *
Your answer
Emergency contact email
Your answer
Please read or listen carefully to the following statements and the SIGN BELOW: 1) I understand that more than 3 absences within a 3-month period may result in my dismissal from the club in order to allow someone else to attend in my place. 2) I understand that Texas Advocates/Next Chapter Book Club staff may photograph and/or videotape me and I agree that they may use these photos and/or videos for the purpose of telling other people about the book clubs. 3) I understand that I may be asked to pay for a replacement book if I lose one. 4) I understand that NCBC cannot provide transportation to or from the book club meeting. I will make arrangements to arrive at book club meeting on time and I will be picked up on time. 5) I understand that book club volunteers cannot provide one-to-one behavior support or medical assistance and I will bring someone to help me if I have behavioral or immediate medical support needs. 6) I understand that Texas Advocates can ask me to leave the club if my behavior is disruptive, aggressive, or puts other members of the book club at risk.
Signature of Book Club member *
Your answer
Date *
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Signature of Guardian (if appropriate)
Your answer
Date
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Name and phone number of person responsible for scheduling/transportation, if different from above.
Your answer
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