Family Registration Form
My Child's Information
Child's Full Name
Child is Called By
Child's Hebrew Name
City, State, Zip
How can you best be reached when your child is in our care?
What Synagogue, if any, are you affiliated with? (Optional)
If divorced child lives with
Medical and Emergency Information
A. In case of emergency, when neither parent can be reached, please give the names of two people who will take responsibility for your child.
B. If parents can not be reached, and emergency medical advice is needed, permission is given to The Friendship Circle of Brownstone Brooklyn staff to phone my child's doctor.
C. Further Medical Information - Medical Concerns/Diagnosis
Other Medical Information
What are your child's favorite activities?
What makes your child upset?
Does your child exhibit any of the following behaviors?
Biting Cursing Grabbing Hitting Kicking Pulling Hair
What is the best method to handle the situation?
Are there any activity restrictions for your child?
Describe your child's disabilities.
Is there anything else we should know about your child?
How did you hear about Friendship Circle?
It is a pleasure to provide for you and your child. However, it is necessary for the parents/guardians to assume responsibility to oversee activities shared together.
I agree that a parent/guardian will be at my home while the volunteers are interacting with my child for Friends @ Home. By signing below, I release the Friendship Circle, its providers and administrators, from ALL liability for any incident which affects the health, welfare, or safety of my child in the provision of a Friendship Circle program for the year 2010/2011.
I permit my child to be transported to and from excursions while he/she is in their care.
Friends at Home
Please Register My Child for Friends at Home
First Choice Day of Week
Please Choose a Day
First Choice Time
Second Choice Day of Week
Second Choice Time
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