Friendship Club: Social-Emotional Development
Registration Form
Child's Full Name:
First Name
Last Name
Nickname or Preferred Name:
Date of Birth:
-
Month
-
Day
Year
Date
Grade Level:
Age:
Parent/Guardian Full Name:
First Name
Last Name
Parent/Guardian Preferred Name:
Parent/Guardian Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
example@example.com
Emergency Contact:
First Name
Last Name
Emergency Contact Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Student Information:
What type of educational format is your child currently apart of? (Homeschooled, microschool, public, unschooled etc.)
Is your child diagnosed with learning differences, neurodivergence or have support needs? (*note: this is a neurodiversity-affirming and trauma-informed space. Sharing this information helps me to support your child better.)
Does your child have any triggers or sensitivities that may impact them within the group setting?
What are your child's strengths in social situations?
What are your child's challenges in social situations?
How does your child handle conflict? Big emotions?
What are your goals for your child being in this club?
Medical/Emergency Information:
Allergies?
Medical Conditions?
Medications? (If relevant during club times)
Permission to administer basic first aid?
Yes
No
Child's Primary Care Physician:
First Name
Last Name
Primary Care Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
In the event of a medical emergency, I authorize the program facilitator to seek emergency medical treatment for my child if I cannot be reached immediately. I understand that reasonable efforts will be made to contact me first.
I agree
Signature:
More Information:
Permission for your child to be photographed during clubs for promotional content?
Yes
No
Payment for this club is $180/month with a sibling discount. Payment is due on the 1st of every month. Will you be using ESA or personal pay?
Is there anything else you'd like to share about your child that will help them feel safe, seen and supported in this space?
I look forward to connecting with you all and having your child with us in our Friendship Club 🤍
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