2018-2019
Friendship Circle Participant Intake Form

Filling out this form does not guarantee your child a spot in our program. Once we receive this form, a staff member will reach out to you to talk about next steps to complete your registration!

Child's Info

Child First Name

 Child Last Name

DOB:

Nickname:

Address

 

 

City

State: Zip

Primary Contact

Phone Number

Relationship

If you belong to a synagogue or temple, which one?

We are careful about your child's safety and the safety of our staff and volunteers. Please provide a personal reference:

Name Relationship

Phone Email

Parent Info Parent 1:    

Name

Occupation

Cell Phone
Wireless Carrier
E-Mail
 
 
     
Parent Info
Parent 2:
 
 
Name
Occupation
Cell Phone
Wireless Carrier
E-Mail
 
 
 
 
Annual Membership Fee: $360

Membership fees help to offset the cost of programs and allows us to offer         programs to everyone who needs it. Once your child is accepted into the program, a staff member will follow up with instructions on completing payment.

Please indicate if you are able to pay the full amount at once, would like to       pay in quarterly installments, or if you need assistance with a scholarship.

$360 Annual Fee ( I will pay the full Annual Membership Fee at once)

$90 Quarterly Fee (I will pay the Qtrly Fee: 4 Payments/year of $90 each)

I need assistance with a Scholarship OR I plan to use DDA funds in place of paying a membership fee (staff will reach out to you to discuss)

 
Information About Your Child

Please fill out the following information about your child. Please be as detailed and specific as possible, so that we can best understand where you child is coming from and how we can support their growth and success in our program.

What are some of your child's strengths and hobbies (ex. sports, art, social, academic)?

What is challenging for your child? (ex. loud, crowds, social, lack of structure)?

What are some challenging behaviors we might encounter?

Throwing Scratching Screaming Running Away Tantrums

Other Behaviors

Under what circumstances do these behaviors typically occur (ex. loud, over whelmed, hungry, tired)?

What strategies do you use to prevent or mitigate these behaviors?

How does your child most successfully communicate (ex. leading, verbally, sign/gesture, picture symbols, etc)?

What reinforcement strategies do you use with your child?

Please share any diagnoses your child has. Please also share any therapy your child is receiving (ex. Occupational Therapy, Physical Therapy, Speech and Language, Behavioral (ABA), etc).

Medical Information

Emergency contact name
(other than parent)

Phone


 

Primary Care Doctor

Phone


Please list any allergies
 
Do any of these allergies require immediate emergency medical attention?
Please list any medical conditions that we should be aware of.
 
Programs

Please check off which programs your child is interested in participating in. All listed programs are covered by your membership fee, unless otherwise noted. We welcome donations and never turn anyone away because of financial need.

Friends @ Home - Friends@Home gives children with special needs the chance to bond with teen volunteers in the environment in which they are most comfortable, their own home. Volunteers visit their buddy at home 2-3 times per month for an Children and their volunteers bake cookies, play games, create arts ‘n crafts, read books or do just about anything fun!

When would you like volunteers to come and visit your home?

1st choice
Day of the week

Time

2nd choice
Day of the week

Time

If you currently have a F@H volunteer, would you like to: keep the same volunteer(s) or have new volunteer(s)
   
Respite Service Agreement  
Friends At Home partners with you to ensure that a parent or guardian is home to assume responsibility and oversee activities. Teen volunteers are not to be left to assume responsibility for your children.
I/We (Parent/Guardian) release the Friendship Circle, its providers and administrators, from all liability for any incident which affects the health, welfare or safety of (child) in the provision of such service.

Sunday Circle -  Two Sundays per month during the school year, trained specialists and a team of teen volunteers lead children through art, music, and movement therapy, Kung Fu, games, and other fun activities.

Teen Scene & Teens On the Go - The mission of our teen programs are simple—that all teens, regardless of ability, deserve the opportunity to build bonds and gain skills alongside their friends. During these activities, teens with and without special needs come together for skill-building, movies and activities in the community. 

Birthday Club - Children with special needs are often excluded from birthday parties and miss out on opportunities to socialize. The Friendship Circle brings kids together to eat cake, celebrate, and see their friends. The agency hosts bi-monthly birthday and holiday celebrations for children with special needs and their families.

Commitment Statement

Friendship Circle partners with families to ensure the safety, fun and friendship for children and teens with special needs. As part of our programming, I agree to:

  • RSVP at least three days prior to programs my child plans to attend;
  • Notify the FC promptly when I know that my child is unable to attend an event they were RSVP'ed for;
  • Provide a parent/guardian that will be a responsible contact for my child during FC programming (contact can vary from event to event);
  • Disclose all critical and supporting information about my child that will help FC staff and volunteers ensure his/her fun and safety. 


Release of Liability

I/We (Parent/Guardian) release the Friendship Circle, its providers and administrators, from all liability for any incident which affects the health, welfare or safety of (child) in the provision of such service.

 

I allow photographs and video of my child to be used by Friendship Circle in publications and on social media.
Yes
No

Relationship to child
Father Mother Legal Guardian
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