Friendship Circle Participant Application
Child's Name
*
First Name
Last Name
Childs Hebrew Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Current Age:
Gender
*
Male
Female
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
School/ Program/ Job/ Other?
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Father's Title
Please Select
Mr.
Dr.
Rabbi
Esq.
Other
Parent's (Legal Guardian) Information:
Father's Name
*
First Name
Last Name
Father's Email
example@example.com
Father's Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Occupation
Mother's Title
Please Select
Ms.
Mrs.
Miss.
Dr.
Esq.
Other
Mother's Name
*
First Name
Last Name
Mother's Email
*
example@example.com
Mother's Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Occupation
Parent's Marital Status
Married
Divorced
Widowed
Other
Participants Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Other Info
Medical Concern/ Diagnosis
Does your child have any allergies, dietary restriction or food sensitivities?
*
Yes
No
If you selected yes -please list all below, with as much details as possible.
Does your child carry an epi pen?
Yes
No
Please describe any medical conditions that we should be aware of (ie. seizures and how to respond)
List any medication your child is currently taking
Additional notes about safety and health info.
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Emergency Information
In case of emergency and a parent cannot be reached. Emergency Contact name:
*
First Name
Last Name
In case of emergency and a parent cannot be reached. Emergency Contact name:
*
First and Last name
Relationship to your child
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Getting to know your child
Give a brief description of your child
List child's favorite activities
List child's least favorite activities (what frustrated him/her)
Is your child toilet trained? (bathroom habits?)
Does your child occasionally exhibit any of the following behaviors?
Biting
Hitting
Kicking
Pulling hair
Elopement
What do you recommend we do to avoid/ deal with it?
Is your child sensitive to any of the following
Light
Movement
Noise
Touch
Other
How does your child communicate
Verbal
Non-Verbal
Sign
Communication Device
Other
What do you hope your child will gain by Participating in the Friendship Circle activities?
How did you hear about the Friendship Circle?
Additional comments, concerns or suggestions?
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Family
Siblings 1: Name, Age
Siblings 2: Name, Age
Siblings 3: Name, Age
Siblings 4: Name, Age
Siblings 5: Name, Age
Additional Siblings
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Waiver
It is our pleasure to provide you with our Friends at Home program. However please note- it is the parent/guardians responsibility to oversee activities and be at home during the duration of the visit. I/We agree that a parent or legal guardian will be home at all times while volunteers are interacting with my/our child. I release the Friendship Circle, its providers and administrators from all liability of an incident which affect the health, welfare or safety of any child, in their provision of such service. (Please sign your agreement below)
I permit my child’s photos to be used for Friendship Circle publicity purposes (social media, brochures, newspapers).
*
I agree
I do not agree
I herby give my child permission to participate in all activities planned by Friendship Circle. (Please initial your agreement below)
*
I hereby give Friendship Circle permission to transport my child to and from an excursion while my child is in their care and I have been notified. (Trips/ Camp) (Please initial your agreement below)
*
Our insurance requires that anyone over the age of 18 that will be in the house during a Friends@Home visit need to complete a background check. I agree to a background check. (Please initial your agreement below)
*
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 my pertinent medical information above. I agree to the terms and condition of this application. (Please initial your agreement below)
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Friendship Circle’s Code of Conduct:
As a Parent of a child involved in the Friendship Circle: I understand that Friendship Circle will match my child with a teenage volunteer. I understand that, it is necessary for me as parent(s)/guardian(s) to assume full oversight and supervision responsibilities with respect to all activities Friendship Circle’s assigned teen mentor(s) share(s) with my child in connection with his/her participation in the program. I agree to respect the privacy of all participants of the Friendship Circle and to keep personal information confidential. If someone gets hurt or some other detrimental incident occurs, it is my responsibility to immediately report the occurrence to Friendship Circle Staff.AS AN EXPRESS PRECONDITION OF YOUR CHILD’S ADMISSION INTO THE PROGRAM, THISPARENTAL CONSENT FORM MUST BE SIGNED AND RETURNED TO THE FRIENDSHIP CIRCLE.EXECUTION OF THIS PARENTAL CONSENT FORM SERVES AS YOUR ACKNOWLEDGEMENT: (1)OF THE CRITCIAL IMPORTANCE FRIENDSHIP CIRCLE PLACES ON YOUR AGREEMENT TO AT ALLTIMES HAVE AT LEAST ONE PARENT/GUARDIAN “ON PREMISES” DURING THE ENTIRETY OFEACH PROGRAM RELATED VISITATION; AND (2) THAT THE PARENT/GUARDIAN TAKES FULLRESPONSIBILITY FOR EVERYTHING THAT TRANSPIRES DURING THE VISIT AND EXEMPTSFRIENDSHIP CIRCLE FROM ANY RESPONSIBILITY; AND (3) THE FAILURE TO ABIDE BY THISREQUIREMENT MAY, IN THE EXERCISE OF FRIENDSHIP CIRCLE’S SOLE AND ABSOLUTEDISCRETION, RESULT IN THE TERMINATION OF ALL FURTHER PROGRAM RELATEDVISITATIONS WITH YOUR CHILD.
I have carefully read agree to abide and be bound by all additional rules and policies in the Friendship Circle Handbooks and any additional rules pertinent to specific events. (Please initial your agreement below)
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I give my child permission to participate in Friendship Circle. I understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and give consent for myself or my child to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct as set forth in the Friendship Circle Handbook, as it may be modified from time to time. I understand that this local Friendship Circle is an independent owned, operated and controlled. I, myself and on behalf of my child, release Friendship Circle and its employees, directors, officers and volunteers as well as all other organizations associated with Friendship Circle from any and all claims or liability arising out of this participation. (Please initial your agreement below)
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COMMITMENT TO EVERYONE’S SAFETY AND WELL-BEING
Friendship Circle provides unique opportunities for volunteers, children, teens and their families tosocialize and have fun. In doing so, most participants will encounter new and sometimes challengingsituations. Thus, it is imperative to set expectations at the beginning so that volunteers, friends, andparents understand what they can expect. Therefore, volunteers, friends, and their families each certifyand agree by checking each box and signing below that they:Understand that participation in this activity is entirely voluntary and requires participants to abide byapplicable rules and standards of conduct;Understand that participation in Friendship Circle activities involves a certain degree of risk and can bephysically, mentally, and emotionally demanding. I have carefully considered the risk involved and havegiven consent for me and/or my child to participate in this activity;Do not use or possess any illegal drug, alcohol or controlled substances at any time, including atFriendship Circle events or programs;Do not have any alcohol or tobacco products at Friendship Circle events or programs, including Friendsat Home;Do not bring any weapons, firearms or other dangerous items to any Friendship Circle event or program;Do not have any unsecured firearms in a home which hosts a Friends at Home program;Have not and do not have any individual that has been convicted of a crime, other than minor trafficviolations, living at or visiting a home that hosts a Friends at Home program and have not themselvesbeen convicted of a crime;Do not themselves have and do not have any individual that has a history of violence or abuse of any kindliving at or visiting a home that hosts a Friends at Home program;Agree to a background check.Acknowledge the risk of injury from the activities involved in the Friendship Circle events or program andknowingly and freely assume all such risks;Will not participate in any activity that you believe you and/or your child cannot perform in accordancewith the Friendship Circles activities’ instructions or in a safe manner;If you observe any significant hazard during your participation in any Event, you will stop participating inthe event and inform the Friendship Circle of such hazard immediately;Agree Friendship Circle is not responsible for any damages to personal property or injury in which theFriendship Circle had no knowledge of the particular hazard or any activity outside of Friendship Circlesponsored events;Acknowledge that Friendship Circle is an independently owned, operated and controlled local corporation.Release Friendship Circle, the directors, board, officers, activity coordinators, and all employees,volunteers, related parties, and other organizations associated with the activity from any and all claims orliability arising out of this participation;In case of emergency involving my child, I understand every effort will be made to contact me. In theevent I cannot be reached, I hereby give my permission to the medical provider selected by the adultleader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections ofmedication for my child. Medical providers are authorized to disclose to the adult in charge examinationfindings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’sability to continue in the program activities.
Parent/Guardian's Signature
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Todays Date:
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Month
-
Day
Year
Date
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