24'-25' Program Selection

BS"D

I am selecting programs for a:*

Returning ParticipantNew Participant

Did you complete the New Participant Application form?

Yes, I didNo, I didn't

You must complete the New Participant Application before you can continue.

Did you attend an intake meeting?

Yes, I didNo, I didn't

You must complete an intake meeting before you can select programs. Please email jen@fcla.org to schedule your intake meeting.

Participant's name*

First NameLast Name

Parent/guardian name*

First NameLast Name

Parent/guardian email address:*

example@example.com

Parent/guardian phone number:*

Is there anything NEW we need to know about your child?*

Are there any new behaviors we need to know about?*

YesNo

Please Describe:

Has the participant's contact information changed in the last year?*

Yes, participant's contact information has changedNo, participant's contact information has not changed

New Participant Email (if applicable and needs to be updated)

example@example.com

New Home Phone (if needs to be updated)

New Home Address (if needs to be updated)

Street Address

Street Address Line 2

CityState

Zip Code

New Parent/Guardian Status

Child Lives With

Has the parent/guardian's contact information changed in the last year?*

Yes, parent/guardian's contact information has changedNo, parent/guardian's contact information has not changed

Mother's Name

First NameLast Name

Mother's Hebrew Name

Mother's Mobile Phone

Mother's Mobile Phone (if needs to be updated)

Mother's Occupation

Mother's Place of Employment

Mother's Work Address

Street Address

Street Address Line 2

CityState

Zip Code

Mother's Work Phone

Mother's Work Phone (if needs to be updated)

Mother's Email

example@example.com

Mother's Email (if needs to be updated)

example@example.com

Synagogue Affiliation

Father's Name

First NameLast Name

Father's Hebrew Name

Home Address (if different than child's)

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone (if different than child's)

Father's Mobile Phone

Father's Mobile Phone (if needs to be updated)

Father's Occupation

Father's Place of Employment

Father's Work Address

Street Address

Street Address Line 2

CityState

Zip Code

Father's Work Phone

Father's Work Phone (if needs to be updated)

Father's Email

example@example.com

Father's Email (if needs to be updated)

example@example.com

Synagogue Affiliation

Child's Legal Name*

First NameLast Name

Any presenting medical conditions or allergies? If yes, please list medications and frequency.

If not applicable, please enter "None"

If yes, please specify any special reminders or assistance your child needs

Is your child on a restrictive diet?*

YesNo

If YES, please provide details:

Is your child toilet trained?*

YesNo

Doctor*

First NameLast Name

Doctor's Phone Number*

Insurance Carrier*

Policy Number*

Insurance Phone Number*

Have there been any changes in your child's medical condition/information within the past year?*

YesNo

Please Provide Details:

Are there any changes in your child's insurance information within the past year?*

YesNo

Please Provide Details:

Do you have new emergency contacts?*

YesNo

Please Provide Details:

If your child has any NEW allergies and/or dietary restrictions, please list them:

Emergency Contact #1 Name*

First NameLast Name

Emergency Contact #1 Mobile Phone*

Emergency Contact #1 Relationship to Child*

Emergency Contact #2 Name*

First NameLast Name

Emergency Contact #2 Mobile Phone*

Emergency Contact #2 Relationship to Child*

Medical: As the parent/legal guardian of {fullName3}, I authorize any adult acting on behalf of Friendship Circle Los Angeles to hospitalize or secure treatment for my child and I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Friendship Circle personnel will try, but are not required, to communicate with me prior to such treatment.

Trips and Outings: I hereby give permission for my child, {fullName3} to attend and participate in all trips and outings organized as part of the program by Friendship Circle.

Medical & Trip Agreement: Parent/Guardian Signature*

Friendship Circle provides very special and unique opportunities for volunteers, special friends and their families to enrich the lives of each other. In doing so, participants might encounter new and sometimes challenging situations. Thus, it is imperative to set expectations at the beginning so that volunteers, special friends, and parents understand what they can expect. Therefore, volunteers, special friends, and their families must each certify and agree by signing below that they:

Understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct;
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 have given consent for me and/or my child to participate in this activity;
Acknowledge the risk of injury from the activities involved in the Friendship Circle events or program and knowingly and freely assume all such risks;
Will not allow me/my child to participate in any activity that I believe me/my child cannot perform in accordance with the Friendship Circles activities’ instructions or in a safe manner;
If I observe any significant hazard during my child's participation in any event, I will stop participating in the event and inform the Friendship Circle of such hazard immediately;
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 or liability arising out of this participation provided that care was taken to ensure safety;
In case of an emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me/my child. Medical providers are authorized to disclose to the adult in charge examination findings, 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’s ability to continue in the program activities.

I give Friendship Circle permission to use my or my child's name, image, likeness or recording in connection with any promotional materials including, but not limited to, brochures, advertising and broadcasts. *

YesNo

Commitment to Safety & Well-Being/Publicity: Parent/Guardian Signature*

DOWNLOAD OUR NEW PROGRAM GUIDE HERE

Program Coordinator: Luba | Luba@fcla.org

Friends @ Home Registration:*

Yes, I'm Registering for Friends @ HomeNot Registering for Friends @ Home

1st Choice: Day of the Week & Time

2nd Choice: Day of the Week & Time

Any pets owned? If yes, which pets?

If none, indicate "none"

Friends @ Home Respite Agreement

It is our pleasure to provide you with your Friends at Home service. However, it is necessary for a parent/guardian to assume responsibility and oversee activities shared together:

I/we agree that a parent/legal guardian will be at home at all times while volunteers are with my/our child.

I/we release the Friendship Circle, its providers, and administrators, from all liability for any incident that affects the health, welfare, or safety of {participantsName} in the provision of such service.

Friends @ Home Code of Conduct

As a parent or guardian of a child who has special needs participating in the Friendship Circle:

I understand that Friendship Circle will match my child with either a preteen/teenage or adult 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 incident occurs during a Friendship Circle program, 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, this parental consent form must be signed and returned to the Friendship Circle. Execution of this parental consent form serves as your acknowledgement: (1) of the critical importance Friendship Circle places on your agreement to at all times have at least one parent/guardian “on premises” during the entirety of each program related visitation; and (2) that the parent/guardian takes full responsibility for everything that transpires during the visit and exempts Friendship Circle from any responsibility or liability; and (3) the failure to abide by this requirement may, in the exercise of Friendship Circle’s sole and absolute discretion, result in the termination of all further program related visitations with your child.

I have carefully read and agree to abide and be bound by all additional rules and policies in the Friendship Circle Handbook and any additional rules pertinent to specific events.

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 and/or my child to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide and be bound by all applicable rules and policies as set forth in the Friendship Circle Friends @ Home Handbook, as it may be modified from time to time and any additional rules pertinent to specific events. I understand that this local Friendship Circle is independently owned, operated and controlled. I release the Friendship Circle and its employees, directors, officers, and volunteers as well as its affiliates and all other organizations associated with Friendship Circle from any and all claims or liability arising out of this participation.

Respite Agreement & Code of Conduct Signature

Release to Perform a Background Check (For Friends @ Home)

I hereby grant the Friendship Circle of Los Angeles permission to perform a background check on me as required by the law. This information will be kept confidential.

Mother's Full Legal Name

First NameLast Name

Mother's Date of Birth

Date

Mother's Social Security Number

If applicable. If NOT applicable, please just enter "not applicable".

Signature

Father's Full Legal Name

First NameLast Name

Father's Date of Birth

Date

Father's Social Security Number

If applicable. If NOT applicable, please just enter "not applicable".

Signature

Program Coordinator: Doonie Mishulovin | Doonie@fcla.org

Date & Time: Sundays, September 15, 2024 - June 8, 2025 | 9:15am-1:00pm

Fall (2024): Sep 15, 22 | Nov 3*, 10, 17, 24 | Dec 8, 15
Winter (2025): Jan 12, 19, 26 | Feb 2, 23 | Mar 2, 9
Spring (2025): Mar 23, 30 | Apr 27 | May 4, 18 | Jun 8

*division B only

Division A: Girls and boys ages 5-12
TTYA: Girls ages 13 and up
Division B: Boys ages 13 and up

Torah Social Registration*

Yes, I'm Registering for Torah SocialNot Registering for Torah Social

My child will be attending:

Division A: Girls and boys 5-12TTYA: Girls ages 13 and upDivision B: Boys ages 13 and up

Program Coordinator: Racheli Sabbagh | racheli@fcla.org

For boys only. Ages 8 and up

Date & Time: Wednesdays, September 18, 2024- June 11, 2025 | 6:30pm-8:00pm

Fall (2024): Sep 18, 25 | Oct 9 | Nov 6, 13, 20 | Dec 4, 11, 18
Winter (2025): Jan 15, 29 | Feb 5, 12, 19, 26 | Mar 5, 12
Spring (2025): Mar 19, 26 | Apr 2, 30 | May 7, 14, 28 | Jun 11

Kicks & Hoops Registration*

Yes, I'm Registering for Kicks & HoopsNot Registering for Kicks & Hoops

Program Coordinator: Racheli Sabbagh | racheli@fcla.org

For Girls only. Ages 12 and up

Date & Time: Mondays, September 16, 2024 - June 9, 2025 | 5:00pm-6:30pm

Fall (2024): Sep 16, 23 | Oct 7 | Nov 4, 18, 25 | Dec 2, 9
Winter (2025): Jan 13, 27 | Feb 3, 10, 24 | Mar 3, 10
Spring (2025): Mar 17, 24, 31 | Apr 28 | May 5, 12 | Jun 9

Girls' Scene Registration*

Yes, I'm Registering for Girls' SceneNot Registering for Girls' Scene

Program Coordinator: Racheli Sabbagh | racheli@fcla.org

Div A - For girls & boys ages 5-12
Div A+ - For girls ages 13 and up
Div B - For boys ages 13 and up

Winter Camp 2024

Dates: 12/23/2024 - 1/3/2025 (Monday - Friday)
Camp Times: 9:00am - 4:00pm (1:30pm on Fridays).

*No camp Wednesday, Dec 25 and Wednesday, Jan 1

Summer Camp 2025

Dates: 7/21/2025 - 8/8/2025 (Monday - Friday)
Camp Times: 9:00am - 4:00pm (2:00pm on Fridays)

Winter Camp - (Separate form required to register for camp.)

Yes, I'm interested in Winter Camp 2024

Summer Camp - (Separate form required to register for camp.)

Yes, I'm interested in Summer Camp 2025

My child is part of:*

Regional CenterPrivate Pay / Financial Aid

Traditional Regional Center or Self-Determination?:*

Traditional Regional CenterSelf-Determination

* Please note, FCLA currently works with Westside Regional Center, Lanterman Regional Center, and NLACRC. All others will have a delay in funding. Please email jen@fcla.org for further assistance.

* No one is turned away due to financial hardship. For a scholarship request, please email billing@fcla.org.

Which Regional Center?

Name of your child's Service Coordinator

Service Coordinator's Phone Number

Service Coordinator's Email Address

example@example.com

Are you transitioning to Self-Determination?

Yes, transitioning to Self-DeterminationNo, not transitioning to Self-Determination

When are you starting Self-Determination?

Date

Which FMS do you use?

FMS Invoicing Code

Which code do we need to use when invoicing your FMS?

Phone Number of FMS

Email address to submit invoices

example@example.com

When does your budget renew?

Date

* Please Note: Services will only be rendered to families who have Friendship Circle of LA in their Spending Plan for this year. Please contact jen@fcla.org for instructions.

Have you added your selected programs to your spending plan for this year?*

Yes, the programs I selected are in my spending plan for this year.No, the programs I selected are not in my spending plan for this year.

* Please Note: Services will only be provided to children for whom we've obtained a POS (Traditional RC).

Fee Schedule:

We are vendored with Westside Regional Center. If you are affiliated with either Westside Regional Center or Lanterman Regional Center please contact your Service Coordinator and request these services using the codes below. If you are part of NLACRC or any other Regional Center, please contact Jen (jen@fcla.org) for instructions.

Traditional Regional Centers:

Program	Category	Vendor Number	Service Code	Amount Covered
Torah Social	Social-Rec	PW8359	008 - Sports Club	$1,500/month for 10 months
Kicks & Hoops	Social-Rec	PW8359	008 - Sports Club	$1,000/month for 10 months
Girls' Scene	Social-Rec	PW8359	008 - Sports Club	$1,000/month for 10 months
Winter - Summer Camp	Social-Rec	HW0425	850-Camping Services	$250/Day - $1,250/Week

If you have entered into Self-Determination, our programs are Self-Determination friendly. Please make sure to add us to your yearly budget. Contact Jen if you have any questions or need guidance: jen@fcla.org.

Torah Social: $15,000
Kicks & Hoops: $10,000
Girls' Scene: $10,000
Winter Camp (2 weeks): $2,500
Summer Camp (3 weeks): $3,750

For those paying upfront, or requiring a payment plan, please fill out the payment section below. Scholarships and financial assistance can be requested by emailing billing@fcla.org. No one will be turned away due to a lack of funds!

Because you have indicated that your child will receive government funding, or that you require financial assisitance, no amounts are due today. Someone from our office will be in contact with you regarding program funding and any payments that may be due.

I/we would like to help sponsor the activities of another child in need:

Optionally enter a donation amount to be added to the subtotal above

Total Amount Due for Torah Social

Total Amount Due for Kicks and Hoops

Total Amount Due for Girls Scene

Total Amount Due for Winter Camp 2024

Total Amount Due for Summer Camp 2025

TOTAL OF PROGRAMS

TOTAL AMOUNT DUE TODAY

I would like to pay by:

Credit CardI will send a check

Credit Card Payment

USDTotal to be charged today

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

24'-25' Program Selection Form

Returning Participant Information Update

Parents/Guardian Information

Medical Information

Insurance Information

Emergency Contact Information

Medical & Trip Declaration

Commitment to Safety & Well-Being

Choose From Our Programs

Friends @ Home Program

Torah Social

Kicks & Hoops

Girls' Scene

Winter & Summer Camp

Summary & Submit