Welcome to Friendship Circle at Valley Chabad! We are so glad you’re here. At Valley Chabad, every child is embraced with warmth, love, and respect. Our Friendship Circle programs ranging from sports, music, cooking, baking, and art, to Friends at Home visits and fun community activities are designed to create joy, friendship, and meaningful inclusion for children with different needs. Your family is not only welcome here you are an important part of our community, and we look forward to having you! Parent/Guardian's Name* First Name Last Name Cellphone* Area Code Phone Number E-mail* Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country YOUR CHILD’S INFORMATION Full Name* First Name Last Name Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Cellphone Area Code Phone Number E-mail School* Grade* FRIENDSHIP CIRCLE REGISTRATION What is your relationship to the child?* MotherFather Father's Name* First Name Last Name Father's Phone* Area Code Phone Number Father's E-mail* Mother's Name* First Name Last Name Mother's Phone* Area Code Phone Number Mother's E-mail* I am interested in...* Friends@HomeFamily Holiday ProgramsAssisting with Friendship Circle future events When would you like to have the volunteers visit your child? First Choice Day of the week* Time* Second Choice Day of the week* Time* Does your child occasionally exhibit any of the following behaviors? BitingAggressiveGrabbingHittingKickingPull Hair What is your child’s special need?* What are your child’s favorite indoor and outdoor activities? What makes your child happy/upset? Other things you would like to tell us about your child? PARENTAL CONSENT The Friendship Circle is an organization designed to provide a friend for your child. This program doesn’t provide tutoring, babysitting, therapeutic, referral, clinical, psychological, social, or medical services. Therefore it is imperative for a parent. or Guardian to be at my home while the volunteers are interacting with my child. By signing below, I understand to its terms and conditions and I also give my permission for this information to be given to the teen who will befriend my 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 during these programs. I permit my child’s photo to be used for publicity purposes* YesNo Signature of Parent* Date* Month Day Year GENERAL INFORMATION Further explanation of Medical Concerns/Diagnosis (if necessary): Names and ages of siblings residing in home with child: Give brief description of your child attention span, eye contact, easy to interest, happy/sad, outgoing/shy: Describe your child’s communication skills Please list your child’s least favorite activities What would you most like your child to gain by participating in Friendship Circle activities? MEDICAL AND EMERGENCY INFORMATION Medical Concerns/Diagnosis Medications Taken Regularly Any activities that your child should not be participating in Medicinal/Environmental/Pet Allergies Dietary Restrictions VegetarianLactose Intolerant Emergency Contact Full Name* First Name Last Name Relationship* Home Phone* Area Code Phone Number Office Phone Area Code Phone Number Doctor’s Name Doctor's Office Phone Area Code Phone Number Hospital Affiliation [It is the responsibility of the parent/guardian of the named applicant to inform the Friendship Circle of any changes to the information on this form] PARENT MEDICAL AND EMERGENCY RELEASE My son/daughter has my permission to attend Friendship Circle events. I agree not to hold Friendship Circle liable for any accident, loss or theft that may occur during the course of an event. I hereby give my permission to the physician selected by the Friendship Circle to hospitalize, and/or secure necessary treatment or anesthesia for my child, as named above, in the event that I cannot be reached in an emergency. I hereby give my permission that paramedics can transport my child to the nearest hospital, if necessary. I have indicated any pertinent medical information above. I agree to the terms and conditions of this application. Additionally, I am initialing below all that I am agreeing to by my signature below. I hereby give my child permission to participate in all activities planned by Friendship Circle (unless stated above) Yes Parent/Guardian Signature* Date* Month Day Year Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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