2024 Social Groups - October Adult Hangout #1

October Adult Hangout #1: Cooper's Hawk Winery & Restaurants!

Registration open through September 30th, or until at capacity

Join your friends and the Cooper's Hawk staff for an evening of drinks, appetizers, and a fall craft in the private dining room! Thank you so much to the team at Cooper's Hawk for generously sponsoring this evening out! Parents/caregivers are encouraged to drop off and dine on your own, or enjoy the tasting room!

*Participant drinks will be non-alcoholic.

Date: Monday, October 7th

Time: 5:30-7:30pm

Location: Cooper's Hawk Winery & Restaurants

(11792 W Broad St, Richmond, VA 23233)

Cost: $5

Ages: High School graduates through age 40

Amount *	Quantity
$5 - Participation fee
$0 - Full financial assistance

Refund Policy *

Jacob's Chance is able to process refunds upon request, up to one week prior to the start of the program/session, minus a 10% processing fee. Jacob’s Chance will not process refunds for fees below $10.

I acknowledge and accept the terms of the refund policy.

Optional Donation - Support the Mission!

$100

$50

$25

$10

Family Contact Information

Parent/Guardian Name *

First Name

Last Name

Email *

Verify Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Participant Information

Name *

First Name

Last Name

Birthdate *

(mm/dd/yyyy)

Participant Diagnosis *

Any accommodations requested/helpful tidbits? *

Is there anything we should know about the participant to ensure they have the most success possible?

Does the participant have any allergies? (dietary or outdoor) *

Jacob's Chance will not administer any medication, so any rescue medication must be brought and administered by guardian/participant

Demographic Data *

Data collection is used only for grant compliance and internal review purposes. Check all that apply

Caucasian

Black or African American

Asian

Indigenous American or Native American

Native Hawaiian or Pacific Islander

Hispanic or Latino

Not of Hispanic Origin

Not interested in reporting

Gender Identity *

Data collection is used only for grant compliance and internal review purposes. Check all that apply

Male

Female

Non-binary

Other

Not interested in reporting

Requested pronouns (examples: he/him, they/them, she/her)

Policy Agreements/Waivers

Jacob’s Chance requires all participants, family members, caregivers, staff, board members, and volunteers to conduct themselves in a safe and respectful manner to help maintain a comfortable, safe, and fun environment. In order to engage in Jacob's Chance programs, everyone must read thoroughly and agree to the terms established by the documents below.

Jacob's Chance Code of Conduct

Jacob's Chance Program Policies

Jacob's Chance Risk, Media, & Concussion Waivers

I have read fully, and agree to the terms established by the waivers/policies linked above. *

Yes

Name of the person responding to the above waivers/policies, on behalf of the participant registered. *

First Name

Last Name

Add 3% to my total amount to help cover the payment processing fees