Full Circle Family Services - Participant Enrollment

Participant Enrollment
Today's Date*

MonthDay Year
Date
How did you hear about Full Circle Family Services?
Participant Information
Participant Name

First Name Last Name
Phone Number
Participant Email
Address

Street Address

City, State, Zip

City

Zip Code
Birth Date

Month Day Year
Age
Gender

FemaleMaleOther
School Currently Attending
Grade
Parent/Guardian Information
Whom does your child primarily live with?

Mother OnlyFather OnlyBoth ParentsSelfStudentOther
Parent/Guardian Name

First Name Last Name
Parent/Guardian Phone
Relationship to you
Parent/Guardian Address

Street Address

City, State, Zip

City

Zip Code
Emergency Contact Information
Emergency Contact Name

First Name Last Name
Emergency Contact Phone
Relationship to you

Authorization for Medical Treatment
This release and consent gives Full Circle Family Services Inc. permission to take my child to the nearest available medical facility and have any necessary emergency treatment administered. I understand that every effort will be made to contact me. However, in case of emergency, if I cannot be reached, I hereby give Full Circle Family Services Inc. permission to act on my behalf in seeking medical treatment by qualified personnel for my child in the event that such treatment is deemed necessary or advisable for my child’s health, safety and welfare. I release Full Circle Family Services Inc. and all medical providers from liability in acting on my behalf in this regard in rendering such medical treatment.

This authorization for Emergency Medical Treatment must be completed before participant can participate in any activities. Treatment for injury will be based on information provided herein.
Student CAN be administered Tylenol, Ibuprofen, Antacids, Benadryl, Throat Lozenges, & topical ointments (hydrocortisone and antibiotic ointment) by Staff nurse.

YesNo
Current Medications: (Medications must be sent with participant in their original containers.) Medication name for dosage.
HEALTH CONCERNS (Please identify any allergies (to include foods), health problems, medications, or other health concerns)

Release of Liability
Full Circle Family Services Disclaimer (click to read)
I have read and understand the Full Circle Family Services Disclaimer.

I ACCEPT
I hereby grant permission for my daughter/son to participate in the Full Circle Family Services Inc. Mentor Program. I understand and acknowledge that this program is voluntary, and there is no requirement that my daughter/son participates in this program. If any other contacts are planned, the mentor will obtain advanced, written parental permission. Finally, I understand that I may withdraw my permission at any time by written notification and that my daughter/son will thereafter be withdrawn from the mentor program.
Would you like your child to participate in the mentoring program?

YesNo
I understand that participating in Full Circle Family Services Inc activities is a privilege. In consideration of this privilege, I release Full Circle Family Services Inc, including its directors, volunteers, employees and agents from any physical injury I understand that my child and/or I may participate in any number of activities, some of which include, but are not limited to, recreational activities and games. I understand that there are certain risks associated with any activity; I will assume responsibility for these risks, whether known or unknown to me at this time. This release is also intended to include all claims of my family, estate, heirs, personal representative or assigns. If I am under 18, my parent or guardian, by signing below, also consents to my release and he or she agrees that this release shall be binding upon him or her as my parent or guardian as to me and my estate, heirs, personal representatives and assigns. My parent or guardian also promises, by signing below to defend, indemnify and hold Full Circle Family Services Inc harmless from any claim asserted by me against Full Circle Family Services Inc, including its directors, volunteers, employees and agents, if I should repudiate this release after obtaining adulthood. Consent I hereby grant permission to Full Circle Family Services Inc the right to use, reproduce, and/or distribute photographs, films, videotapes, and sound recordings of my child, without compensation or approval rights, for use in materials created for purposes of promoting the activities of Full Circle Family Services Inc.
I have read and understand the Release of Liability agreement.

I ACCEPT
ACKNOWLEDGEMENT and SIGNATURE
I UNDERSTAND THAT THIS IS A LEGAL AGREEMENT that is binding upon myself and my heirs, executors, administrators, successors and assigns. I HAVE READ AND UNDERSTAND THE TERMS OF THIS AGREEMENT and I ACKNOWLEDGE THAT by signing this agreement voluntarily, I am agreeing to abide by its terms and I am waiving certain legal rights that my child or I may have.
Participant Signature (If participant is emancipated, proof must be provided prior to activity.)

Clear
Parent/Guardian Signature (If participant is a minor.)

Clear
Should be Empty:

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Participant Enrollment

Participant Information

Parent/Guardian Information

Emergency Contact Information

FAMILY DEMOGRAPHICS

Authorization for Medical Treatment

Release of Liability

ACKNOWLEDGEMENT and SIGNATURE