Printed from SharonFriends.com

 


 

CHILD APPLICATION (*designates required fields) 

 

FIRST NAME*:   LAST NAME*:  
GENDER: MALE  FEMALE  AGE: 
DATE OF BIRTH*:    SCHOOL:
ADDRESS*:     CITY*   
STATE: MA ZIP CODE:
HOME PHONE* CELL PHONE*:
E-MAIL ADDRESS*:   

PREFERED METHOD OF CONTACT: 

       
 

PARENTS' INFORMATION

   
FATHER'S NAME: MOTHER'S NAME:
FATHER'S MOBILE: MOTHER'S MOBILE:
FATHER'S E-MAIL:  MOTHER'S E-MAIL:    

PROGRAMS OF INTEREST (You can check as many as you'd like):  

 FRIENDS AT HOME         HOLIDAY PROGRAMS

For those who checked box "FRIENDS AT HOME"

1) When would you like a volunteer to come to you home? 

FIRST CHOICE:      SECOND CHOICE:    

2) What does your child enjoy doing most?

 

3) Is there anything in particular that your child does not like doing?

 

4) Is there anything we need to know about your child? 

 

5) Have you been to a SFC program? YES NO 

If YES, which one?

    

6) How'd you hear about the SHARON FRIENDSHIP CIRCLE?

 

QUESTIONS OR COMMENTS:

   

MEDICAL EMERGENCIES

A. Emergency contact, in case neither parent can be reached.

NAME*:

RELATIONSHIP TO CHILD*:
HOME PHONE*: CELLPHONE*:
ADDRESS: CITY/STATE/ZIP:
 
B. If parent cannot be reached and emergency medical advice is needed, permission is given to the Sharon Friendship Circle staff to phone my child's doctor. 
DOCTOR*:

PHONE*:

ADDRESS: CITY/STATE/ZIP:
DOCTOR'S HOSPITAL AFFILIATION: 
 
C. In case of medical emergency requiring immediate care, I authorize the Sharon Friendship Circle staff and/or paramedics to take my child to the nearest hospital to receive medical care.
Health insurance NAME:  NUMBER: 



 

D. Food allergies:

  

E. Additional medical information or comments:

 

   I permit my child's photos to be used for publicity purposes to assist the Valley Friendship Circle. 

As a Parent of a special needs child of Friendship Circle:

1) I understand that as part of the Friends@Home program, the Sharon Friendship Circle will match my child with two teenage volunteers.   
   
2) I understand that it is necessary for me as parent(s)/guardian(s) to assume full oversight and supervision responsibilities with respect to all Sharon Friendship Circle activities  
   
3) I agree to respect the privacy of all participants of the SFC and to keep personal informationconfidential. 
   
4) I understand and agree to, at all times have at least one parent/guardian “on premises” during the entirety the Friends@Home visitation program  
   
5) I agree that the parent/guardian takes full responsibility for everything that transpires during the visit and exempts the Sharon Friendship Circle from any responsibility  
   
6) I give my child permission to participate in the Sharon Friendship Circle.  
   
7) I, myself and on behalf of my child, release the Sharon Friendship Circle and its employees, directors, officers and volunteers as well as all other organizations associated with the SFC from any and all claims or liability arising out of this participation.  
   

 Parent/Guardian’s Signature:   Date: 

 

 

 Email