Friendship Circle Registration

 

Your Child
   
Child's Name:* Gender:*
 
Month
Day
Year
 
Date of Birth :*
 
 
Age:*
       
Address:* City:*
  Postal Code:*
Home Phone :*    
School:* Grade:*
Religion:*    
       
       
Parents
       
Father's Name:*    
Father's Cellphone:* Work Phone:
Father's E-mail:* Occupation:
       
Mother's Name:*    
Mother's Cellphone:* Work Phone:
Mother's E-mail: * Occupation:
       
Parent's Status:* Married    
  Divorced    
  Child living with:
       
       
Medical Information
       
Emergency Contact Name (other than a parent):* Phone:*
Relationship:* Cellphone:*
 
What are your child's special needs?*
       
Please list any allergies or medical conditions
we should be aware of:*
       
       
Siblings
       
Name: School:
 
Month
Day
Year
 
Date of Birth :
 
 
Age:
       
Name: School:
 
Month
Day
Year
 
Date of Birth :
 
 
Age:
       
Name: School:
 
Month
Day
Year
 
Date of Birth :
 
 
Age:
       
 
Additional Information
   
What language does your child speak? *
What are your child's favorite indoor activities?*
Favorites outdoor activities?*
What makes your child happy?*
(Special toys, special activities)
What makes your child upset?*
Does your child occasionally exhibit any of the following behaviors?*
Biting Cursing
Grabbing Hitting
Kicking Pulling Hair
Other:
How does your child communicate
his/her needs and thoughts?*
Are there any activity resctrictions for your child?*
What else should we know about your child?*
         
         
Friends @ Home
         
When would you like the volunteers to come and visit your home?
1st choice      
Day of the week: Time:
       
2nd choice      
Day of the week: Time:
Do you prefer having:
The same volunteers as last year, if available
New volunteers
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.
I/We agree that a parent or legal guardian will be home at all times while volunteers are interacting with my/our child.
 
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.
 
I permit my child’s photos to be used for Friendship Circle publicity purposes.
         
         
Please check off programs your choices:
 
 

Friends @ Home

 You are what you Eat
  Bowling League Community Adventures
  Get Moving
  Birthday Club  
  Holiday Programs  
  Mom's Night Out