Sibling Signup Form

First Name:

Last Name:

Date of Birth:

January February March April May June July August September October November December   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Grade:

Address:

City/State/Zip:

Phone Number:

Cell Phone:

Child's Email Address:

Father's Name:

Father's Email Address:

Father's Cell Phone:

Mother's Name:

Mother's Email Address:

Mother's Cell Phone:

 Friends @ Home: I agree that a parent/guardian will be home while volunteers are interacting with my child.

 Programs: I permit my child to be taken off Friendship Circle premises for special trips.

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  Yes No

Signature: