Child Information

First Name:

Last Name:

Date of Birth:

  


Jewish:

Grade:

Address:

City/State/Zip:

  

Home Phone Number:

Child Cell Phone:

School Attending:

School Phone Number:

 

Parent Information

Father's Name:

Father's Email Address:

Father's Cell Phone:

Mother's Name:

Mother's Email Address:

Mother's Cell Phone:

Marital Status:

 

Additional Information

What does your child enjoy doing most? (both outdoor/indoor activities) 

Are there any fears you'd like us to know about (animals, loud noises, etc) and suggestions of how we can deal with them?

Is there anything else you'd like us to know about your child?

How did you hear about our program?

 Is your child completely toilet trained? 

Does your child need reminders to go to the bathroom?  

I permit my child to be taken off Friendship Circle premises for special trips. (I will be notified in advance)

I release the Friendship Circle, its providers and administrators, from all Liability for any incident which affects the health, welfare, or safety of my child in the provision of such service.

I permit my child’s photos to be used for publicity purposes 

In the event that my child is unable to attend one of the below sessions, I will notify The Friendship Circle as soon as possible so they can plan accordingly. 

Children’s Circle dates 2018-19

Oct 7, 14, 28

Nov 11, 18

December 2, 9

January 6, 13

February 3, 10

March 3, 17, 31

April 7

May 5

Signature: