Welcome to Friendship Circle We are excited to learn more about your child and family. Please complete the registration form below. After submitting the form, a member of our team will contact you to schedule a time to connect, answer any questions, and learn more about your child. We look forward to welcoming your family to Friendship Circle. Participant Information Participant Name Date of Birth Street Address City State Zip Code Parent / Guardian Information Parent / Guardian 1 Name Relationship to Participant Cell Phone Email Parent / Guardian 2 Name (optional) Relationship to Participant Cell Phone Email Preferred Method of Contact Email Phone Call Text Message Synagogue / Congregation (optional) Tell Us About Your Child Tell us about your child. Every child is unique. We’d love to learn more about your child’s personality, strengths, interests, and what makes them special. What are some of your child’s favorite activities or interests? What should we know to help your child have a successful experience at Friendship Circle? Does your child have a diagnosis, disability, or support need you would like us to be aware of? Are there any behavioral, sensory, communication, or safety considerations we should be aware of? Medical & Emergency Information Emergency Contact Name Relationship Phone Number Allergies Medical Conditions Medications (optional) Additional Information How did you hear about Friendship Circle? Friend or Family School Synagogue Social Media Internet Search Community Organization Other: Permissions & Signature Photo Release I allow my child’s photos to be used for Friendship Circle publicity purposes. Yes No Who is completing this form? Parent Guardian Other: Electronic Signature Date Thank you for registering. After submitting this form, a member of our team will follow up to schedule a time to connect. This page uses 128 bit SSL encryption to keep your data secure.
