Your Child Full Name First Name Last Name Birth Date 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Address Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Home Number Area Code Phone Number School Grade in 2023-2024 School Year Parents Parent/Guardian First Name Last Name Cell Number Area Code Phone Number Work Number Area Code Phone Number E-mail Occupation Best way to reach me Home PhoneCell PhoneWork PhoneEmail Parent/Guardian First Name Last Name Cell Number Area Code Phone Number Work Number Area Code Phone Number E-mail Occupation Best way to reach me Home PhoneCell PhoneWork PhoneEmail Parent's Status MarriedDivorcedWidowed If divorced, child lives with: Siblings Please list name, age and school of all additional children Friends @ Home What day of the week would you like the volunteers to come visit at your home? First choice of day Second choice of day What time of the day would you like the volunteers to come visit at your home? First choice of time Second choice of time Do you have specific teens in mind? yesno If yes: Teen's name Phone Number Area Code Phone Number Teen's name Phone Number Area Code Phone Number Are they currently registered as Friendship Circle volunteers? yesno 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? yesno If not, please elaborate Additional Information What are your child's favorite activities? What makes your child upset? Does your child exhibit any of the following behaviors? KickingBitingCursingGrabbingHittingPulling 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? yesno 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): Full Name First Name Last Name Phone Number Area Code Phone Number 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 yesno Mother's Signature Signature Date Father's Signature Signature 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 Submit Should be Empty: This page uses TLS encryption to keep your data secure.