704-366-5983 info@friendshipcirclenc.org

Friendship Loaves
UMatter
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OUR PARTNERS

Thanks for showing that we’re all in this together!

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Founders ~ $180,000+

Dr. Bobby and Stacey Selkin – Center Dedication
Eric and Lori Sklut – Friendship Loft Dedication

Builders ~ $50,000+

Dave and Janice Cantor
David and Aleen Epstein
Eric and Susan Lerner
Andrew and Gwen Lindner
Michael and Dena Raffler
Ed and Leslie Rusgo
Foundation for the Carolinas Longleaf Fund
Hearst Foundation

Corporate Partners

Design Smart USA – Project Design & Oversight
Grainda Builders – Builder

Patrons ~ $10,000+

Caren and Charlie Gale
Stuart and Sherri Goldstein
Stacy and Todd Gorelick
Adriana den Blanken and Mitch Marcus
Meromim Foundation
Fred and Lisa Shporer
Morris B. Squire Foundation
Frank and Lauren Wiseman

Supporters ~ $5,000+

William and Bleema Bershad
Dr. Larry and Stephanie Seitlin

Friends ~ $1,000+

Dr. William and Corine Bocknek
David and Bonnie Bornstein
Gary and Randy DeFilipp
David and Andrea Gamlin
Elise and Jaime Kosofsky
Perla and Leon Klass
Michael Rainerman and Tara Green-Rainerman
Stephen and Alison Schlussel
David and Patricia Stern
Jeannette Strunk

To make a general donation to the Building Fund click the “Become a Partner” button below. If you would like to make a specific dedication please be in touch.

Become a Partner

Step 1 of 4 - Teen Info

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Teen Info

Name*

First Last

Hebrew Name

First Middle

Date of Birth*

MM slash DD slash YYYY

Gender*

M

F

Address*

Street Address City State ZIP Code

Phone

Email

School

Grade*

Synagogue Affiliation

Teen Medical Info

Do you have any allergies?*

Yes

No

Allergies*

Please list one allergy per field and click the + for additional fields.

In case of allergic reaction, what should be done?*

Are there any activities you will not be able to participate in due to a medical condition?*

Are there any additional concerns or information our staff should be aware of to ensure your safety?*

Emergency Contact Info

In case of emergency please contact*

First Last

Relationship to Teen*

Emergency Contact Phone*

Family Information

Mother's Name*

Prefix First Last

Mother's Email

Mother's Phone

Mother's Address:*

Same as Above

Different

Mother's Address*

Street Address City State ZIP Code

Father's Name*

Prefix First Last

Father's Email

Father's Phone

Father's Address:*

Same as Above

Different

Father's Address

Street Address City State ZIP Code

More About You

How did you hear about Friendship Circle AND what made you decide to get involved?*

Which program would you like to join?*

Choose as many as apply

Friends@Home ~ During the week

Group Programs ~ Mostly Sundays

Both

When are you available?*

Please list Days and Times below in order of preference. Use one line/day & time. Click the + to add a line.

Days

Times

Consent

I agree to have my photo used for publicity purposes

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