FC Hebrew Club Registration

To be completed by the parent or guardian of a child with Special Needs.

IMPORTANT: If you have already registered your child with Friendship Circle using the standard registration form, you may skip the following sections: Family Information, Medical Information, General Information. Please complete the remaining sections - thank you!

CHILD INFORMATION

Full Name

First Name Last Name

Hebrew Name

Birth Date

Month Day Year

Age

Grade

School Name

Gender

MaleFemale

Address

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

FAMILY INFORMATION

Mother's Name

First Name Last Name

Mother's Hebrew Name

Mother's E-mail

Mother's Phone Number

Area Code Phone Number

Father's Full Name

First Name Last Name

Father's E-mail

Father's Phone Number

Area Code Phone Number

Marital Status

MarriedSeparatedDivorced

Are there any conversions or adoptions in the family?

YesNo

If yes, please provide details.

MEDICAL INFORMATION

Medical Concerns / Diagnosis

Medications Taken Regularly

Allergies

Any activities your child should not participate in?

GENERAL

Further Explanation of Medical Concerns / Diagnosis (if necessary)

Names and ages of siblings residing in home with child

Give a brief description of your child

Describe your child's communication skills

What would you most like your child to gain by participating in Friendship Circle?

Is your child completely toilet trained?

YesNo

Please list your child's favorite activities

Please list your child's least favorite activities

Are there any pets in your home? If so, please specify:

Please list your child's hobbies

How did you hear about the program?

Other Comments, if any:

PARENT MEDICAL RELEASE

My son/daughter has my permission to participate in Friendship Circle. I agree not to hold Friendship Circle liable for any accident, loss or theft that may occur during the course of an event. I have indicated any pertinent medical information above. I agree to the terms and conditions of this application.

Permission

I hereby give my child permission to participate in all activities planned by Friendship Circle.

Signature & Date

PARENTAL LIABILITY RELEASE

Release

I agree that a parent/guardian will be home while volunteers are interacting with my child. I release the Friendship Circle, its provider and administrators, from all liability for any incident which affects the health, welfare, or safety of my child in the provision of such service.

Signature & Date

MISCELLANEOUS PARENTAL RELEASE

Photo Release

I hereby give permission for my child's photo be put on the Friendship Circle Website and/or Social Media PagesI hereby give permission for my child's photo to be used for publicity purposes

TUITION AND PAYMENT

Schedule: Sunday 10:00 am - 12:00 pm October through May

Annual Tuition: $600.00

If you need a scholarship, please click here to fill out the scholarship application form.

Payment

Credit Card Check

Postal / Zip Code

Country

Payment Plan

Pay in fullSplit my payment over 3 monthsSplit my payment over 6 months

FC Hebrew Club Registration Form

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