So glad you came to join us! Please take a moment to fill out the following form. All information is held in confidence.

Name *
Birth Date *
Birth Date
Phone *
Which is the best number to reach you at?
Which is the best way to contact you? *
Please choose all that apply.
(If you don't have a current address, please use the address of the shelter or home that you mostly stay in. If you don't know, you may leave this blank.)
Please choose one.
Working/School Status *
Please choose any or all that apply.
Parent/Guardian Information
Parent/Guardian Information
If you are under age.
Parent/Guardian Phone Number
Parent/Guardian Phone Number
This is in case of emergency.
Emergency Contact *
Emergency Contact
If there is an emergency, who is the best person for us to reach out to on your behalf?
Emergency Contact Phone Number *
Emergency Contact Phone Number
Please use the phone number that is the most accessible.
Thank you for sharing! We're looking forward to connecting and having you a part of Keramiko! Someone will be in contact with you soon!