Day Program Registration - FloridaFriendshipCircle.com

Guardian Name*

First Name Last Name

Participant Name*

First Name Last Name

Birth Date*

Month Day Year

E-mail*

Phone Number*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please provide a brief overview of any behavioral, developmental, or physical challenges the participant may have, including any activities they cannot do*

Does participant have any allergies or food sensitivities?*

YesNo

Please list allergies and/or food sensitivities*

Does participant take any medications?*

YesNo

Please list all medications*

Participant's Dr*

Dr's Phone Number*

Emergency Contact*

First Name Last Name

Emergency Contact Phone*

*

Please check this box to display the form

1. Permission and Consent

I, the undersigned legal guardian of the above-named participant, give full permission for the participant to participate in all activities organized by Friendship Circle of North Broward and South Palm Beach. This includes but is not limited to:

On-campus activities,
Off-campus events and excursions, and
Transportation to and from activities.

I understand that all activities will be conducted under appropriate supervision, but I acknowledge and accept that there are inherent risks involved.

2. Assumption of Risk

I acknowledge that participation in these activities may involve certain risks, including but not limited to physical activity, travel, and outdoor events. I voluntarily assume all risks associated with participation on behalf of the participant.

3. Medical Authorization

In the event of an emergency, I authorize Friendship Circle staff or representatives to obtain medical treatment for the participant as deemed necessary. Friendship Circle will make every effort to contact me or the emergency contact listed below before initiating treatment, unless delay would pose a serious health risk.

4. Release of Liability

In consideration of the participant's involvement in Friendship Circle’s programs, I agree to release, indemnify, and hold harmless Friendship Circle, its officers, staff, volunteers, agents, and representatives from any and all claims, liabilities, damages, or expenses arising from the participant’s involvement in any activities.

5. Transportation Consent

I grant permission for the participant to be transported by Friendship Circle staff, volunteers, or contracted transportation providers to and from program activities.

6. Media Release

I consent to Friendship Circle’s use of photographs, videos, or other media of the participant for promotional purposes, including social media, print materials, and the organization’s website.

Final Acknowledgment*

I, the undersigned, certify that I am the legal guardian of the participant named above. I confirm that I have read and understood all sections of this waiver, including Permission and Consent, Assumption of Risk, Medical Authorization, Release of Liability, Transportation Consent, and Media Release. By signing below, I agree to all terms and conditions outlined in this waiver. I confirm that I have read and understood all sections of this waiver and agree to the terms outlined above.

Electronic Signature*

First Name Last Name

Today's Date*

Month Day Year

at Hour Minutes

Payment Options*

Check - (Receive 10% discount if you pay balance in full)Credit Card (Receive 10% discount if you pay balance in full, or set up monthly payments)

Check Payment Plan*

Monthly Installments - I will send a check today for $150, and ensure a check is delivered by the 1st of the month January - SeptemberBalance in Full (Receive 10% discount) - I will send a check today for $1,350

Credit Card Payment Plan*

10 Monthly Installments - I will pay the first installment today, and Friendship Circle will charge my card on file every month January - September (Receive 10% discount)Balance in Full (Receive 10% discount)

Today's Credit Card Payment:

$0.00

Please mail a check payable to:
Friendship Circle

and mail to:
7170 Loxahatchee Road
Parkland, FL 33067-3901

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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Liability Waiver, Consent, and Release Form

1. Permission and Consent

2. Assumption of Risk

3. Medical Authorization

4. Release of Liability

5. Transportation Consent

6. Media Release