Child First name

Child Last name

Birthday

Month

Day

Year

Gender

Male

Female

Address

Home Phone

Email

School

Religion

Disability

Grade

How did you find out about Friendship Circle?

Parent Contact Information

Mother's Name

Mothers Email

Mothers Cell

Mother's Occupation

Father's Name

Father's Email

Father's Phone

Add your text

Father's Occupation

Help Us Get to Know Your Child a Little Better

Does your child need supervision and support during bathroom routines? (If yes, please explain)

Describe your child's strengths and weaknesses in the areas of social, cognitive , physical and communicative domains

Any special fears of which we need to be aware? For example: Water, bright lights, animals etc.

Any personality conditions of which we need to be aware? For example: Shyness, hiding, wandering away, tantrums etc.

Are there any special things your child likes? For example: Running, jumping drawing, painting, sports, animals, music etc.

What are some things that upset your child/ For example: Transitions, loud noises, new people etc.

Health and Safety

In case of an emergency "ICE", when neither parent can be reached, please provide the name of someone who will take responsibility for your child

Full Name

Relation

Home Phone

Cell Phone

Safety Details

Medications Taken Regularly

Any activities that your child should not participate in due to a limitation or medical condition

Dietary Restrictions

Parental 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 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 that I am agreeing to by my signature below.

hereby give my child permission to participate in all activities planned by Friendship Circle (unless stated above)

I hereby give permission to administer the medications to my child, upon my request as per written instructions (non-emergency)

I give permission for my child's photo to be used for publicity purpose (i.e., brochures, social media, newspapers, website, etc.)

Programs

The Friends @ Home program gives children the chance to get to know their volunteers in an environment that they are most comfortable - their own homes. The volunteers generally visit for 1 hour weekly. Once we receive your form, our coordinators will find an appropriate match for your child. The time frame for finding a match depends on age, location, and flexibility.

Volunteer Preference

Girl Volunteer

Boy Volunteer

Notes on timing

Register Your Child

Parent Contact Information

Help Us Get to Know Your Child a Little Better

Health and Safety

Programs