Family Registration Form - Chabad of South Broward

FAMILY INTAKE FORM

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

CHILD INFORMATION

Full Name*

First NameLast Name

Hebrew Name

Birth Date*

MonthDayYear

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 NameLast Name

Mother's Hebrew Name

Mother's E-mail*

Mother's Phone Number*

Area CodePhone Number

Father's Full Name*

First NameLast Name

Father's E-mail*

Father's Phone Number*

Area CodePhone 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*

Other Comments, if any:

FRIENDS AT HOME

How 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*

*

HourMinutes

Second Choice*

*

HourMinutes

Third Choice*

*

HourMinutes

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