3- Parent Child Application

Circle of Friends

Parent/Guardian/Child Application
Please fill out this application as completely as possible. Information may be shared with adult members of the Circle of Friends with whom your child is paired.
Today's date

MonthDayYear
Date
Child's Name

First NameLast Name
Child's gender
Childs' date of birth

MonthDayYear
Date
Current Age
Childhood allergies
Child's Routine Medications
Child's food recommendations or limitations
Any known medical conditions?
Parent/Guardian Name

First NameLast Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email Address
example@example.com
Street address
City
State
Zip Code
Mailing address
Relationship with the child
Primary language spoken at home
Employer
Your work status
Current work, volunteer and/or school schedule
Level of education completed
What do you hope the Circle of Friends program can do for your child?
Can you make a one year commitment to Circle of Friends?
Have you discussed Circle of Friends with your child?
Please list any questions you have about Circle of Friends
Should be Empty:

Circle of Friends