Participant Application Form

Participant's Information
Full Name*
First Name Last Name
Birth Date*

Month Day Year
Age*
Gender*

MaleFemale

Address*

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

Home Phone*

Area Code Phone Number
School
Grade
If applicable, place of employment
Family Reference*
First name Last name
Tell us more about your child!
Please share your child's diagnosis & anything else you might want us to know.
Please share about your child's interests and hobbies.
Please share what you are looking to gain out of your participation in Friendship Circle? Why are you joining?
Parent Information
Responsible Party*

MomDad
Responsible Party's Email*
Father Name*
First Name Last Name
E-mail*
Cell Number*

Area Code Phone Number
Occupation*
Mother Name*
First Name Last Name
E-mail*
Cell Number*

Area Code Phone Number
Occupation*
Synagogue Affiliation*
Medical & Emergency Information
A. In case of an emergency when neither parent can be reached please provide the name of a person who will assume responsibility for your child. B. If parents cannot be reached and emergency medical advice is required, permission is granted to The Friendship Circle staff to contact my child's physician. C. In case of a medical emergency where immediate medical care is necessary, I authorize the paramedics to take my child to the nearest hospital.
Full name*
First Name Last Name
Relationship to participant*
Cell Phone*

Area Code Phone Number
Physician's name*
First Name Last Name
Physician's Phone number*
Area Code Phone Number
Health Insurer*
Policy Number*
Allergies*
Medications*
Programs
I would like my child to participate in the following programs:*

Friends at Home: One hour "hangout" or "playdate" once a week throughout the school year.Inclusive Holiday Programs & Birthday Parties (Seasonal)
Let us know if you'd like to celebrate your birthday with Friendship Circle Write your child's birthday, age turning, prefered Sunday closes to bday date. Include your child hobbies/ interest and a venue to celebrate (ex: bowling)
Parental Permission
If my child participates in the Friends at Home program, I agree that a parent/guardian will be present in the home to supervise them*

Consent
I permit my child's photo to be used for publicity purposes.*

Consent
I hereby release the Friendship Circle, its providers and administrators from ALL liability resulting from any incident which affects the health, welfare or safety of my child while participating in a Friendship Circle program for the year 2026-27.*

Consent
Comments
Annual Registration Fee*

$100

Payment

Credit Card Paypal

Postal / Zip Code

Country

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Programs

Participant Application Form

Participant's Information

Tell us more about your child!

Parent Information

Medical & Emergency Information

Programs

Parental Permission

Adult Education

Women's Events

Hebrew School

Friendship Circle