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Register Your Child

Register Your Child

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Register Your Child

Child Information

First Name:

Last Name:

Date of Birth:

Jewish Birthday (if known):

Address

City/State/Zip:

Phone Number:

Cell Phone:

Child's Email Address:

School Attending:

Synagogue:

Additional Information

Parent One Name:

Parent Two Name

Parent One Cell Phone:

Parent Two Cell Phone:

Parent One Email Address:

Parent Two Email Address:

Reference Name:

Reference Email Address:

Reference Phone Number:

Preferences
For next year I am interested in:


Are there any particular board games/sports that your child enjoys?
Does Your Child Enjoy Puzzles
Word Finds
Music
Crafts
Building
Other
What do you hope your child will receive by participating in Friendship Circle programs
Are you available to drive the volunteers to or from your home Yes No

When would you like volunteers to visit?:

First Choice: Day:

Time:

Second Choice: Day:

Time:

Does Your child occasionally exhibit any of the following behaviors

Biting
Cursing
Grabbing
Hitting
Kicking
Pull Hair
Other

What is the best method of handling the situation

Other things you would like to tell us about your child?
Please list your child's favorite activities

Please list your child's least favorite activities

Medical Information
Explanation of Medical Concerns
(if necessary)
Any pets at home Yes No
Is your child completely toilet trained Yes No
Does your child have any fears
How does he/she like to be greeted
Date of last tetanus shot
Please list any Medical/Environmental/Pet Allergies
Dietary Restrictions
Medical Insurance Carrier
Policy Number
Emergency Contact Information

Emergency Contact

Relationship

Home Phone:

Office/Cell

Pick-up Allowed Yes No Doctor's Name:
Office Number
Medical and Emergency Release

My child 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:

I hereby give permission to administer medications to my child, upon my request as per written instructions

Signature

Date 2016

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