Family Registration Form My Child's Information Child's Full Name (First, Last) Child is Called By Birthday Current Age Street Address City, State, Zip Home Phone School Current Grade To ensure we best accomodate you please mark which FC location/s you plan on attending. FC Parkland/ Boca Raton- and surrounding areas Please list the names and ages of all your children. name: age: name: age: name: age: name: age: name: age: Parent's Information Father's Name Father's Email Mother's Name Mother's Email Father's Cell Phone Mother's Cell Phone How can you best be reached when your child is in our care? What Synagogue, if any, are you affiliated with? (Optional) Medical and Emergency Information A. In case of emergency, when neither parent can be reached, please give the names of two people who will take responsibility for your child. Contact #1: Name Phone Cell Phone Relationship Address City Contact #2: Name Phone Cell Phone Relationship Address City B. If parents can not be reached, and emergency medical advice is needed, permission is given to The Friendship Circle of North Broward & South Palm Beach staff to phone my child's doctor. Doctor Phone Address City C. Further Medical Information - Medical Concerns/Diagnosis Allergies Medications Other Medical Information Parental Consent It is a pleasure to provide for you and your child. However, it is necessary for the parents/guardians to assume responsibility to oversee activities shared together. I agree that a parent/guardian will be at my home while the volunteers are interacting with my child for Friends @ Home. By signing below, 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 a Friendship Circle program for the year 2024/2025. I permit my child’s photo to be used for publicity purposes. I permit my child to be transported to and from excursions while he/she is in their care. Friends at Home Please be patient as we work on pairing a local volunteer with your child. Please Register My Child for Friends at Home No Fee First Choice Day of Week Please Choose a Day Sunday Monday Tuesday Wednesday Thursday Friday Shabbat First Choice Time Second Choice Day of Week Please Choose a Day Sunday Monday Tuesday Wednesday Thursday Friday Shabbat Second Choice Time This page uses 128 bit SSL encryption to keep your data secure.
