Child Registration

Fathers Name:*

First NameLast Name

Fathers E-mail:*

Fathers Cell:*

Area CodePhone Number

Home Phone:

Area CodePhone Number

Mothers Name:*

First NameLast Name

Mothers E-mail:*

Mothers Cell:*

Area CodePhone Number

Parent's Status:

MarriedWidowedDivorcedSeperated

Primary Address:*

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

Child's Name:*

First NameLast Name

Is your child Jewish?*

YesNo

Synagogue affiliation:

Date of Birth:*

MonthDayYear

Gender:*

MaleFemale

What are your child's unique needs?

Please select program(s) you are interested in:

What is your availability for Friends@Home?

What times of day work best for Friends@Home?

Please list any allergies:

Please list any medical conditions that we should be aware of:

Emergency Contact Name (other than parent):

Cell Number

Area CodePhone Number

Other things you would like to tell us about your child:

Communication*

I am verbalI am not verbal

What is the best way to communicate with me?

Food:*

I can eat aloneI need assistance eating

Are there any food limitations or a special diet?

Behavior

I like to...

I don't like to...

If I need to be redirected, this is what helps me:

Bathroom*

I can go independentlyI need assistanceI am not toilet trained

Special instructions:

Signature*

In the event that my child is unable to attend any of the programs I sign up to, I will notify the Friendship Circle.

I allow my child's photo to be used for any and all Friendship Circle publicity purposes.*

YesNo

Who is filling out this form?*

FatherMotherLegal Guardian

Please type your signature:*

Comments or Questions:

Friendship Circle Child Registration

Parent Information

Tell us about your child

Medical Information

All About Me!