Friendship Circle Form

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

Cellphone*

Area CodePhone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail*

School*

Grade*

Parent's Names

Father's Phone*

Area CodePhone Number

Father's E-mail*

Mom's Phone*

Area CodePhone Number

Mom's E-mail*

I am interested in...*

[email protected]Family 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?

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*

MonthDayYear

Further explanation of Medical Concerns/Diagnosis (if necessary):

Names and ages of siblings residing in home with child:

Give brief description of your childattention 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 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 NameLast Name

Relationship

Home Phone

Area CodePhone Number

Office Phone

Area CodePhone Number

Doctor’s Name

Doctor's Office Phone

Area CodePhone 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*

MonthDayYear

YOUR CHILD’S INFORMATION

FRIENDSHIP CIRCLE REGISTRATION

GENERAL INFORMATION

MEDICAL AND EMERGENCY INFORMATION

Toddlers

Youth

Teens

Adults

Friendship Circle

Upcoming