Online Registration - SIGN YOUR CHILD UP HERE!

Online Registration - SIGN YOUR CHILD UP HERE!

 

 

2016-2017
Friendship Circle Registration Form

Child's Info

First Name

Last Name

DOB:

Nickname:

Address

 

 

City

State: Zip

Primary Contact

Phone Number

Relationship

If you belong to a synagogue or temple, which one?

We are careful about your child's safety and the safety of our staff and volunteers. Please provide a personal reference:

Name Relationship

Phone Email

Parent Info Father    

Name

Occupation

Cell Phone
Wireless Carrier
E-Mail
 
 
     
Parent Info
Mother
 
 
Name
Occupation
Cell Phone
Wireless Carrier
E-Mail
 
 
 
 
Annual Membership Fee: $360

Friendship Circle provides respite programming for children with special needs year-round. Membership helps to offset the cost of programs and offer programs to everybody who needs it.

$360 Annual Fee ( I can pay the full Annual Membership Fee)

$90 Quarterly Fee (I can pay the Quarterly Fee: 4 Payments/Year)

I need assistance with a Scholarship

Name on Card:

Card Type: Card #:

Exp Date: Month Year: Card COD:

Billing Address:

City: State: Zip:

 
Information About Your Child

Please fill out the following info about your child. This will help us be able to service your child in a safe environment for our children and volunteers.

What are some of your child's strengths and hobbies (ex. sports, art, social, academic)?

What is challenging for your child? (ex. loud, crowds, social, lack of structure)?

What are some challenging behaviors we might encounter?

Throwing Scratching Screaming Running Away Tantrums

Other Behaviors

Under what circumstances do these behaviors typically occur (ex. loud, over whelmed, hungry, tired)?

What strategies do you use to prevent these behaviors?

How does your child most successfully communicate (ex. leading, verbally, sign/gesture, picture symbols, etc)?

How does your child cope in challenging situations and how could we best support him/her (deep breathing, re-directions, quiet time)?

Please share any therapy your child is receiving (ex. Occupational Therapy, Physical Therapy, Speech and Language, Behavioral (ABA), etc).

Medical Information

Emergency contact name
(other than parent)

Phone


 

Primary Care Doctor

Phone


Please list any allergies
 
Do any of these allergies require immediate emergency medical attention?
Please list any medical conditions that we should be aware of.
 
Programs

Please check off which programs your child would be interested in participating in. All programs are free unless otherwise noted. We welcome donations and never turn anyone away because of financial need.

Friends @ Home (Visits are free)

Friends@Home gives children with special needs the chance to bond with teen volunteers in the environment in which they are most comfortable, their own home. Children and their volunteers bake cookies, play games, create arts ‘n crafts, read books or do just about anything fun!

 

When would you like volunteers to come and visit your home?

1st choice
Day of the week

Time

2nd choice
Day of the week

Time

Would you be interested in having the same volunteer(s) or new volunteer(s)
   
Respite Service Agreement  
Friends At Home partners with you to ensure that a parent or guardian is home to assume responsibility and oversee activities. Teen volunteers are not to be left to assume responsibility for your children.
I/We (Parent/Guardian) release the Friendship Circle, its providers and administrators, from all liability for any incident which affects the health, welfare or safety of (child) in the provision of such service.

Sunday Circle - Every other Sunday, trained specialists and a team of teen volunteers lead children through art, music, and movement therapy, Kung Fu, games, and other fun activities.

Teen Scene -Teen Scene facilitates teens with special needs and college volunteers to enjoy meaningful activities and experiences together.

Holiday Programs - Holiday Programs enable children with special needs, their families, and their volunteer friends to experience Jewish holidays and customs in a festive, welcoming environment.

Commitment Statement

Friendship Circle partners with families to ensure the safety, fun and friendship for children with special needs. As part of our programming, I agree to:

  • Notify the FC promptly when I know that my child is unable to attend an event or receive a visit from a volunteer.
  • Provide a parent/guardian that will be a responsible contact for my child during FC programming (contact can vary from event to event).
  • Disclose all critical and supporting information about my child that will help FC staff and volunteers ensure his/her fun and safety.


I allow photographs and video of my child to be used by Friendship Circle in publications and on social media.

Yes
No

Relationship to child
Father Mother Legal Guardian
Please type your signature: Date:
Please enter your email address:
An email receipt will be sent to this email address
 
 

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