First name *

Last name *

Date of birth *

Address *

City *

State *

Zip *

Phone *

Email

How do you generally travel to places? (i.e. bus, walk, taxi, someone drives me, I drive, etc.) *

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

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) *

Emergency Contact Person *

Relationship to that person

Emergency contact phone number *

Emergency contact email

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 *

Date *

Signature of Guardian (if appropriate)

Date

Name and phone number of person responsible for scheduling/transportation, if different from above.