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Participant Enrollment Form

Who is completing this application?

Myself

Guardian

Other (write in)

In a few words can you please tell us how you heard about the Friend 2 Friend program?

Free Text

Name *

Field label

Free Text

Address *

New Field:

Living Status

Independent House or Apartment

Group Home

With parents or guardians

Other (write in)

Are you your own legal guardian?

Yes

No

Unsure

Phone

Email

Date of birth

Gender

Male

Female

Trans Male

Trans Female

Gender Queer/Nonbinary

Other (write in)

How do you communicate with people?

Verbally

American Sign Language

Video remote interpreting

Notetakers

Large print materials

Captioning

Accessible electronic and information technology

Other: Write In

Please select all that apply to you

I need assistance with eating meals.

I do NOT need assistance with eating meals.

I need assistance with using the restroom.

I do NOT need assistance with using the restroom.

I have been hospitalized in the past year for a physical condition such as surgery or an accident.

I have been hospitalized in the past year due to psychiatric or mental health reasons.

I have NOT been hospitalized for any reason in the past year.

Please select any of the following assistive means you use to help with mobility. Please select all that apply

Wheelchair

Walkers

Canes

Crutches

Scooter or Electric Wheelchair

Service Animal

Other: Type In

I do NOT use any assistive mobility device.

How do you get to events you want to go to? Please check all that apply

Uber/Lyft

The Ride

MBTA (Train or Bus)

Parents

Group Home Transportation

Walk

Bike

Other: Write In.

Please select all of the times you would generally be available to meet with a Friend in our program on MONDAYS – FRIDAYS.

8AM – 12PM

12PM – 5PM

5PM – 9PM

Please select all of the times you would generally be available to meet with a Friend in our program on SATURDAYS.

8AM – 12PM

12PM – 5PM

5PM – 9PM

Please select all of the times you would generally be available to meet with a Friend in our program on SUNDAYS.

8AM – 12PM

12PM – 5PM

5PM – 9PM

Please select which of these personality traits best describe you. (Write In)

Which version of the Friend 2 Friend program are you more interested in? Please re-visit the 2-minute video at the top of the page for an explanation of the program versions.

MAGIC

Community

I am interested in both programs.

Thank you for applying to join the Friend 2 Friend program with Jewish Big Brothers Big Sisters of Greater Boston. A Friend 2 Friend Clinical Match Specialist will be in touch with you soon to discuss the next steps.

Participant Enrollment Form

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