Children's Circle Registration Information: Full Name* First Name Last Name Parent Email* Additional Information: What does your child enjoy doing most? (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 your child completely toilet trained?* Yes No Does your child need bathroom assistance?* Yes No Is there anything else we should know about your child? Total Amount scholarships available upon request 150 Payment Credit Card Other Credit Card Visa MasterCard American Express Discover Credit Card Type Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 Expiration Year scholarships available upon request Billing Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Parental Consent: I permit my child's photos to be used for publicity purposes:* Yes No I permit my child to be taken off Friendship Circle premises for special trips.* Yes No 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.* Yes Waiver: The Friendship Circle is strictly adhering to the CDC guidelines and taking all precautions to ensure a safe environment for all participants. I have carefully considered the risk involved and agree to allow my child(ren) to participate in the activities with The Friendship Circle. I also understand that Participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct as set forth by Friendship Circle. I understand that Friendship Circle is independently owned and operated. In consideration of the opportunity to send my child to The Friendship Circle, and by engaging in participation, I, myself, and on behalf of my child, hereby agree to release, hold harmless and waive any and all claims against The Friendship Circle and its employees, directors, officers, and volunteers as well as its affiliates and all other organizations associated with The Friendship Circle from any and all claims or liability arising out of this participation. I understand that this form involves release of legal rights. ~ By entering my initials below, I agree to each statement above and release The Friendship Circle of Fairfield County from any and all liability. Today's Date Month Day Year Parent Signature* Submit Should be Empty: This page uses TLS encryption to keep your data secure.