Your Child
Child's Name (First/ Last)
Hebrew Name
Male Female
Birth Date / / Age
Day Month Year
Address
City
Postal Code
School Name Grade
Home Phone Number
Parents:
Fathers Title Father's Name
Father's Occupation
Father's Cell Phone Father's E-Mail
Mothers Title Mother's Name
Mother's Occupation
Mother's Cell Phone Mother's E-Mail
Medical Info
Medical Concern/ Diagnosis
Please list any allergies (environmental, pet, food, medical)
Please list any medical conditions that we should be aware of
List any medications your child is currently taking
In case of an emergency and a parent can not be reached
Emergency contact Name Relationship
Phone number Cell
Important Info:
Give a brief description of your child
List child's favorite activities
List child's least favorite activities (what frustrates him/her)
Describe your child's communication skills
Is your child toilet trained (bathroom habits)
Does your child occasionally exhibit any of the following behaviors?
Biting Hitting Kicking Pulling Hair Other
What would you like your child to gain by participating in the Friendship Circle activities?
How did you hear about the Friendship Circle?
Additional comments, concerns or suggestions?
Siblings
Name Age Birth Date / /
Name Age Birth Date / /
Name Age Birth Date / /
Name Age Birth Date / /
Name Age Birth Date / /
Friends @ Home
Would you like the volunteers to come and visit your child at home once a week, for an hour?
(1st choice) Day of the week Time
(2nd choice) Day of the week Time
Do you prefer having male female
Would you like another volunteer for a sibling (between the ages of 2-7)?
Do you have any pets?
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 of an incident which affect the health, welfare or safety of amy child, in their provision of such service.
I do do not permit my child’s photos to be used for Friendship Circle publicity purposes.
I do do not permit my child's photos to be put on the Friendship Circle web page.
I herby give my child permission to participate in all activities planned by Friendship Circle
I hereby give Friendship Circle permission to transport my child to and from an excursion while my is in their care and I have been notified. (Sunday Circle Trips/ Camp)
My son/daughter has my permission to participate in Friendship Circle. I agree not to hold Friendship Circle liable for any accident, loss or theft that may occur during the course of an event. I have indicated my pertinent medical information above. I agree to the terms and condition of this application. Additionally, I am initialing below all that I am agreeing to by my initials.
Program Selection
Please check off your choices:
Friends @ Home Birthday Club Sibs Circle
Sunday Circle/Sunday Trip End-of-Summer Camp
Moms Night Out Winter Camp Sports Night
Judaica Circle Holiday Program T-YAD Shabbat Party
