Your Child |
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Child's Name:* |
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Gender:* |
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Month
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Day
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Year
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Date of Birth :* |
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Age:*
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Address:* |
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City:* |
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Postal Code:* |
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Home Phone :* |
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School:* |
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Grade:* |
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Religion:* |
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Parents |
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Father's Name:* |
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Father's Cellphone:* |
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Work Phone: |
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Father's E-mail:* |
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Occupation: |
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Mother's Name:* |
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Mother's Cellphone:* |
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Work Phone: |
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Mother's E-mail: * |
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Occupation: |
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Parent's Status:* |
Married |
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Divorced |
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Child living with: |
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Medical Information |
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Emergency Contact Name (other than a parent):* |
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Phone:* |
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Relationship:* |
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Cellphone:* |
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What are your child's special needs?* |
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Please list any allergies or medical conditions
we should be aware of:* |
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Siblings |
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Name: |
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School: |
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Month
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Date of Birth : |
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Age:
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Name: |
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School: |
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Month
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Date of Birth : |
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Age:
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Name: |
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School: |
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Date of Birth : |
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Age:
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Additional Information |
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What language does your child speak? * |
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What are your child's favorite indoor activities?* |
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Favorites outdoor activities?* |
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What makes your child happy?*
(Special toys, special activities) |
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What makes your child upset?* |
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Does your child occasionally exhibit any of the following behaviors?* |
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How does your child communicate
his/her needs and thoughts?* |
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Are there any activity resctrictions for your child?* |
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What else should we know about your child?* |
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Friends @ Home |
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When would you like the volunteers to come and visit your home? |
1st choice |
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Day of the week: |
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Time: |
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2nd choice |
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Day of the week: |
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Time: |
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Do you prefer having: |
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It is our pleasure to provide you with our Friends at Home service. However it is necessary for parent/guardian to assume responsibility to oversee activities shared together. |
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I/We agree that a parent or legal guardian will be home at all times while volunteers are interacting with my/our child.
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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 such service.
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I permit my child’s photos to be used for Friendship Circle publicity purposes. |
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Please check off programs your choices: |
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Friends @ Home
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You are what you Eat |
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Bowling League |
Community Adventures |
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Get Moving
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Birthday Club |
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Holiday Programs |
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Mom's Night Out |
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