Child Information

First Name:

Last Name:

Date of Birth:







Phone Number:

Cell Phone:

Child's Email Address:

School Attending:

School Phone Number:


Additional Information

Father's Name:

Father's Email Address:

Father's Cell Phone:

Mother's Name:

Mother's Email Address:

Mother's Cell Phone:


Which program are you interested in: 

if you'd like Friends & Home, when would you like volunteers to visit?:

First Choice:  Day:


Second Choice:  Day:


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 there anything we need 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?  

 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