Name *
Name
Cell Phone
Cell Phone
Do you speak Spanish? *
Where would you like to serve? (Check all that apply) *
We will do our best to honor your request.
Liability Agreement *
I hereby remise, release and forever discharge Circle of Concern, its employees, agents, servants and all other persons, firms and corporations whomsoever of and from any and all actions, claims and demands, whosoever which claimant now has or may hereafter have on account of or arising out of any accident, casualty and/or action which might happen while participating in programs/events. I further understand that there is no Worker’s Compensation or Accident Insurance furnished by Circle of Concern for such programs/events. I acknowledge that I am responsible for any and all personal medical expenses while participating in all programs/events, and agree to hold harmless Circle of Concern of any and all liability that may arise out of such participation.
Add additional family members below (Optional)
Family Member 1
Family Member 1
Check box only if under 18 years old
Family Member 2
Family Member 2
Check box only if under 18 years old
Family Member 3
Family Member 3
Check box only if under 18 years old
Family Member 4
Family Member 4
Check box only if under 18 years old
Family Member 5
Family Member 5
Check box only if under 18 years old

SUGGESTED DONATION

Use the button below to pay the suggested donation of $15/person or $30/family. These donations help us purchase the supplies for the outreach.

PAY SUGGESTED DONATION ($15/person or $30/family)