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BrownstoneFriendshipCircle.com » Families » Family Registration Form
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Family Registration Form

My Child's Information

Child's Full Name

 

Child is Called By

 

Child's Hebrew Name

Gender

 Male Female

Birthday

 

Age

 

Street Address

 

City, State, Zip

 

Home Phone

 

Email

 

School

 

Grade

 

 

 

Parent's Information

Father's Name

 

Father's Email

 

Occupation

 

Mother's Name

 

Mother's Email

 

Occupation

 

Work Phone

 

Cell Phone

 

How can you best be reached when your child is in our care?

 

What Synagogue, if any, are you affiliated with? (Optional)

 

Parental Status

Married Divorced Widowed

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.

Name

 

Phone

 

Cell Phone

 

Relationship

 

Address

 

City

 

Name

 

Phone

 

Cell Phone

 

Relationship

 

Address

 

City

 

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.

Doctor

 

Phone

 

Address

 

City

 

C. Further Medical Information - Medical Concerns/Diagnosis

Allergies

 

Medications

 

Other Medical Information

 

 

 

 

Additional 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?

      

Parental Consent

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.

 

 

Programs

Friends at Home

 

Please Register My Child for Friends at Home

No Fee

 

First Choice Day of Week

 

 

First Choice Time

 

 

Second Choice Day of Week

 

 

Second Choice Time

 

 

 

       



 

 

 

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