Sign your child up Today!

Child Info

Child's First Name:

Last Name:

Male Female

Age:

Birth Date

Home Phone Number

Address

City

Province

Postal Code

School

Parents Info

Father's Name

Mother's Name

Father's Cell Phone

Mother's Cell Phone

Father's E-Mail

Mother's E-Mail

Parental Status

Married Divorced

If divorced
Child lives with

Synagogue Affiliation:

Important Info

Does your child occasionally exhibit
any of the following behaviors?

Biting Cursing Grabbing Hitting
Kicking Pulling Hair Other

What is your best method of handling the situation?

Other things you would like to tell us about your child

Medical Info

Emergency Contact Name

Phone Number

Cell

Please list any allergies

Medical/ Diagnosis/ Concerns:

Siblings

Name

Age

Name

Age

Name

Age

Friends @ Home

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

Do you prefer having:

New Volunteers
Same Volunteers as Last Year.

Names of previous volunteers:

I permit my child’s photos to be used for Friendship Circle publicity purposes

What are you expectations of Friendship Circle?

What are some of the changes you hope to see in you child?

Would you like the volunteer to concentrate on sibling involvement?

Are there any special activities that should be worked on or introduced?

Are there any concerns regarding the adaptive level of your child while interacting with new persons or in new situations?

Program Selection

You can check off which programs you're interested in and would like to hear more about. We won't charge you before confirming charges with you.

Friends @ Home (Volunteer must consent to being alone with your child at home, if you won't be home.) Free of charge.

Mom's Club. Free of charge.

Family Holiday Programs, Dates coming.

comments:

Payment Details:

Total Amount

Card Type

Visa Master Card

Card #

Name on card

Exp