Friendship Circle Registration Form

Your Child

Child's Name Male Female

DOB (MM/DD/YYYY)

Address

City

State

Zip

Home #

School Grade 2015-16

Parents

Father's Name

Cell # Email

Work # Occupation

Best way to reach me Home Phone Cell Phone Work Phone Email

Mother's Name

Cell # Email

Work # Occupation

Best way to reach me Home Phone Cell Phone Work Phone Email

Parent's Status: Married Divorced Widowed

If divorced, child lives with

Siblings

Name Age School

Name Age School

Name Age School

Additional children:

Friends @ Home

What day of the week would you like the volunteers to come visit at your home?

First Choice: Day of Week Time

Second Choice: Day of Week Time

Do you have specific teens in mind? Yes No

If yes:

Teen's Name Phone #

Teen's Name Phone #

Are they currently registered as Friendship Circle Volunteers? Yes No

For Past Members of friendship Circle ONLY

Please list the volunteers who visited with your child last year:

Volunteer 1:

Volunteer 2:

Volunteer 3:

Were you happy with this arrangement? Yes No

If not, please elaborate below:

Additional Information

What are your child's favorite activities?

What makes your child upset?

Does your child exhibit any of the following behaviors?

Biting Cursing Grabbing Hitting Kicking Pulling Hair

What is the best method to handle the situation?

Are there any activity restrictions for your child?

Is there anything else we should know about your child?

Additional Friendship Circle Programs

Would you like to be notified regarding additional Friendship Circle programs throughout the year?

Yes No

Please indicate the programs of interest:

Holiday Events (Includes Chanukah Celebration, Purim Party, Model Matzah Bakery and Lag BaOmer Festival)

Winter Camps (During New Year's and President's Day vacation)

Mom's/Dad's Night Out (Includes 3 evenings over the course of the year)

Sports League (Monthly sessions)

Birthday Club (Special visit from volunteers on the Birthday Committee)

Medical Information

Emergency Contact (other than parent):

Name Phone #

Please list any allergies or medical conditions we should be aware of:

Respite Service Agreement-Required

It is the Friendship Circle's pleasure to provide its services. However, it is necessary for the parents/guardians to assume responsibility to oversee activities shared together.

By signing below, I agree to ensure that a parent/guardian will be home while volunteers are interacting with my child.

I also agree to release the Friendship Circle, its providers and administrators from all liability from and incident which affects the health, welfare or safety of my child in the provision of such service.

I permit my child's photo to be used for publicity purposes Yes No

Signature of Mother Date

Signature of Father Date

Please use the space below to address any concerns you may have, suggestions you'd like to make, or comments you'd like to share.