YOUR CHILD’S INFORMATION Full Name* First Name Last Name Birth Date* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Cellphone* Area Code Phone Number Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country E-mail* School* Grade* FRIENDSHIP CIRCLE REGISTRATION Parent's Names Father's Phone* Area Code Phone Number Father's E-mail* Mom's Phone* Area Code Phone Number Mom's E-mail* I am interested in...* Friends@Home Family Holiday Programs Assisting 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? Biting Aggressive Grabbing Hitting Kicking Pull 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* Yes No 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 Vegetarian Lactose 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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