Friendship Circle of The Five Towns frienship circle

Child Registration Form

  • Parent's Information

  • Other Information

  • In case of an emergency and a parent cannot be reached

  • Important Information

  • Siblings

  • 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.
  • Please initial your agreement.
  • Please initial your agreement.
  • Please initial your agreement.
  • Please initial your agreement.
  • Please initial your agreement.
  • Program Selection

    Please check off your choices:
  • Friendship Circle’s Code of Conduct

    As a Parent of a child involved in the Friendship Circle:

    I understand that Friendship Circle will match my child with a teenage volunteer.

    I understand that, it is necessary for me as parent(s)/guardian(s) to assume full oversight and supervision responsibilities with respect to all activities Friendship Circle’s assigned teen mentor(s) share(s) with my child in connection with his/her participation in the program.

    I agree to respect the privacy of all participants of the Friendship Circle and to keep personal information confidential.

    If someone gets hurt or some other detrimental incident occurs, it is my responsibility to immediately report the occurrence to Friendship Circle Staff.

    AS AN EXPRESS PRECONDITION OF YOUR CHILD’S ADMISSION INTO THE PROGRAM, THIS PARENTAL CONSENT FORM MUST BE SIGNED AND RETURNED TO THE FRIENDSHIP CIRCLE. EXECUTION OF THIS PARENTAL CONSENT FORM SERVES AS YOUR ACKNOWLEDGEMENT: (1) OF THE CRITCIAL IMPORTANCE FRIENDSHIP CIRCLE PLACES ON YOUR AGREEMENT TO AT ALL TIMES HAVE AT LEAST ONE PARENT/GUARDIAN “ON PREMISES” DURING THE ENTIRETY OF EACH PROGRAM RELATED VISITATION; AND (2) THAT THE PARENT/GUARDIAN TAKES FULL RESPONSIBILITY FOR EVERYTHING THAT TRANSPIRES DURING THE VISIT AND EXEMPTS FRIENDSHIP CIRCLE FROM ANY RESPONSIBILITY; AND (3) THE FAILURE TO ABIDE BY THIS REQUIREMENT MAY, IN THE EXERCISE OF FRIENDSHIP CIRCLE’S SOLE AND ABSOLUTE DISCRETION, RESULT IN THE TERMINATION OF ALL FURTHER PROGRAM RELATED VISITATIONS WITH YOUR CHILD.

  • Please initial your agreement.
  • Please initial your agreement.
  • COMMITMENT TO EVERYONE’S SAFETY AND WELL-BEING

    Friendship Circle provides unique opportunities for volunteers, children, teens and their families to socialize and have fun. In doing so, most participants will encounter new and sometimes challenging situations. Thus, it is imperative to set expectations at the beginning so that volunteers, friends, and parents understand what they can expect. Therefore, volunteers, friends, and their families each certify and agree by checking each box and signing below that they:

    Understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct;

    Understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for me and/or my child to participate in this activity;

    Do not use or possess any illegal drug, alcohol or controlled substances at any time, including at Friendship Circle events or programs;

    Do not have any alcohol or tobacco products at Friendship Circle events or programs, including Friends at Home;

    Do not bring any weapons, firearms or other dangerous items to any Friendship Circle event or program;

    Do not have any unsecured firearms in a home which hosts a Friends at Home program;

    Have not and do not have any individual that has been convicted of a crime, other than minor traffic violations, living at or visiting a home that hosts a Friends at Home program and have not themselves been convicted of a crime;

    Do not themselves have and do not have any individual that has a history of violence or abuse of any kind living at or visiting a home that hosts a Friends at Home program;

    Agree to a background check.

    Acknowledge the risk of injury from the activities involved in the Friendship Circle events or program and knowingly and freely assume all such risks;

    Will not participate in any activity that you believe you and/or your child cannot perform in accordance with the Friendship Circles activities’ instructions or in a safe manner;

    If you observe any significant hazard during your participation in any Event, you will stop participating in the event and inform the Friendship Circle of such hazard immediately;

    Agree Friendship Circle is not responsible for any damages to personal property or injury in which the Friendship Circle had no knowledge of the particular hazard or any activity outside of Friendship Circle sponsored events;

    Acknowledge that Friendship Circle is an independently owned, operated and controlled local corporation.

    Release Friendship Circle, the directors, board, officers, activity coordinators, and all employees, volunteers, related parties, and other organizations associated with the activity from any and all claims or liability arising out of this participation;

    In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

The Friendship Circle of the Five Towns
516-295-2478* 13
Batsheva@chabad5towns.com