Friendship Circle Registration Form 

CHILD'S INFO  
Child's Name*   
First Name                     Last Name
 Gender*  Male     Female
 Birth Date*   
 School
 Current Grade

 

PARENT'S INFO  
Name*   
First Name                     Last Name
Address *
Street Address
  
City ,  State / Province, Postal / Zip Code
Phone Number *
Mother's Email
Father's Email
What Synagogue, if any, are you affiliated with? *

 

IMPORTANT INFORMATION 
Does your child occasionally exhibit any of the following behaviors? Biting Cursing Grabbing Hitting
 Kicking

What is your best method of handling the situation?
Other things you would like to tell us about your child
Does your child require a 1on1 professional aid?   No Yes

 

MEDICAL INFORMATION 

Please list an any allergies.
Please list any medical conditions that we should be aware of
Emergency Contact (other than parent)
Emergency Contact's Cell

  

 

PARENTAL CONSENT

It is a pleasure to provide for you and your child. However, it is necessary for the parents/guardians to assume responsibility to oversee activities shared together.

I agree that a parent/guardian will be at my home while the volunteers are interacting with my child for Friends @ Home. By signing below, I release the Friendship Circle, its providers and administrators, from ALL liability for any incident which affects the health, welfare, or safety of my child in the provision of a Friendship Circle program for the year 2018/2019.

 I permit my child’s photo to be used for publicity purposes.
   

 

FRIENDS AT HOME
Please be patient as we work on pairing a local volunteer with your child.

Please Register My Child for Friends at Home. No Fee
First Choice Day of Week
First Choice Time
Second Choice Day of Week

 

Second Choice Time