Family Registration FormFAMILY INTAKE FORMTo be completed by the parent or guardian of a child with Special Needs.CHILD INFORMATIONFull Name*First NameLast NameHebrew NameBirth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearAge*Grade*School Name*Gender*MaleFemaleAddress*Street AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryFAMILY INFORMATIONMother's Name*First NameLast NameMother's Hebrew NameMother's E-mail*Mother's Phone Number*Area CodePhone NumberFather's Full Name*First NameLast NameFather's E-mail*Father's Phone Number*Area CodePhone NumberMarital Status*MarriedSeparatedDivorcedAre there any conversions or adoptions in the family?*YesNoIf yes, please provide details.MEDICAL INFORMATIONMedical Concerns / Diagnosis*Medications Taken RegularlyAllergies*Any activities your child should not participate in?*GENERALFurther Explanation of Medical Concerns / Diagnosis (if necessary)Names and ages of siblings residing in home with childGive 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?*YesNoPlease 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*Other Comments, if any:FRIENDS AT HOMEHow did you hear about our program?*How many times weekly you'd like to receive Friends at Home?*Dates & Times of convenience for friends to visit:First Choice*SundayMondayTuesdayWednesdayThursdayFridaySaturday Evening*123456789101112Hour001020304050MinutesAMPM Second Choice*SundayMondayTuesdayWednesdayThursdayFridaySaturday Evening*123456789101112Hour001020304050MinutesAMPM Third Choice*SundayMondayTuesdayWednesdayThursdayFridaySaturday Evening*123456789101112Hour001020304050MinutesAMPM PARENT MEDICAL RELEASEMy 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 RELEASERelease*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 RELEASEPhoto 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 purposesSubmitShould be Empty: This page uses TLS encryption to keep your data secure.