Child's First name Child's Last name Gender male female Age Date of Birth Home Address City Province Postal code School Mother's Full Name First Name Last Name Parent's Information Father's Full Name First Name Last Name Mother's Cell Phone Area Code Phone Number Father's Cell Phone Area Code Phone Number Home Phone Area Code Phone Number Parental Status Married Divorced If divorced child lives with Synagogue Affiliation About your child Does your child occasionally exhibit any of these behaviors: biting kicking hitting pulling hair grabbing What is the best method to handle the situation Other things you would like to tell us about your child Medical/ Diagnosis/ Concerns: Please list any allergies Emergency contact name Emergency contact phone numbver Siblings Sibling 1 age Sibling 2 age Sibling 3 age Friends @ Home When would you like the volunteers to come and visit your home? I permit my child’s photos to be used for Friendship Circle publicity purposes yes no What are you expectations of Friendship Circle? What are some of the changes you hope to see in you child? 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. yes no Sunday Circle: $410, early bird fee before September 10- $375 10:45-12:45 yes no Mom's Club. Free of charge. yes no September 17 HIGH HOLIDAY PROGRAM 2 Hour Drop Off program for Friendship Circle Children and Siblings cost $5 a child yes no Family Holiday Programs, Dates coming. yes no Holiday Cooking Club: COST: $8 for 1 class, Age: 8+ yes no Payment details Credit card number Name on card Amount to charge Expiry date Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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