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 2022/2023.

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
  First Choice Time
  Second Choice Day of Week
  Second Choice Time