Child Information

First Name:

Last Name:

Sibling of:

Date of Birth:

  


Jewish:

Grade:

Address:

City/State/Zip:

  

Phone Number:

Cell Phone:

Child's Email Address:


 

Additional Information

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 

Signature: