Your Child's Information
First Name Last Name
Birthday Gender
Address City
State Zip
Home Phone Email
School Religion
Child's Special Need Grade
Parent Information
Mother's Name Father's Name
Mother's Email Father's Email
Mother's Cell Father's Cell
Mother's Occupation Father's Occupation
Synagogue Affiliation Parent's Marital Status
Additional Information
When would you like to volunteer at the home of a child with special needs?
I am interested in Friends at Home I am interested in Family Holiday Programs
I am interested in Fairs and Festivals I am interested in assisting with FC future events
Are you available to drive your child to or from your home? (to)
When would you like to have the volunteers visit your child?
1st Choice Time
2nd Choice Time
Help Us Get to Know Your Child a Little Better
Does your child need supervision and support during bathroom routines? (If yes, please explain)
Describe your child's strengths and weaknesses in the areas of social, cognitive , physical and communicative domains
Any special fears of which we need to be aware? For example: Water, bright lights, animals etc.
Any personality conditions of which we need to be aware? For example: Shyness, hiding, wandering away, tantrums etc.
Are there any special things your child likes? For example: Running, jumping drawing, painting, sports, animals, music etc.
What are some things that upset your child/ For example: Transitions, loud noises, new people etc.
Medical Information
In case of an emergency, when neither parent can be reached, please provide the name of someone who will take responsibility for your child
Name Relation
Phone Cell Phone
Is this person allowed to pick up your child?
Medical Insurance Carrier
Policy Number Doctor's Name
Doctors Office Number Hospital Affiliation
Medical Concerns/Diagnosis
Medications Taken Regularly
Any activities that your child should not participate in due to a limitation or medical condition
Date of last tetanus shot (if known)
Medicinal/Environmental/Pet Allergies
Dietary Restrictions
Parental Medical and Emergency Release
My son/daughter has my permission to attend Friendship Circle events. I agree not to hold Friendship Circle liable for ay accident, loss, or theft that may occur during the course of an event. I hereby give my permission to the physician selected by The Friendship Circle to hospitalize, and/or secure necessary treatment or anesthesia for my child, as named above, in the event that I cannot be reached in an emergency. I hereby give my permission that paramedics can transport my child to the nearest hospital, if necessary. I have indicated any pertinent medical information above. I agree to the terms and conditions of this application. Additionally I am initialing below that I am agreeing to by my signature below.
I hereby give my child permission to participate in all activities planed by Friendship Circle (unless stated above)
I hereby give permission to administer the medications to my child, upon my request as per written instructions (non-emergency)
I give permission for my child's photo to be used for publicity purpose (i.e., brochures, newspapers, website, etc.)
Programs To Get Involved In

Friends at Home

The Friends @ Home program gives children the chance to get to know their volunteers in an environment that they are most comfortable - their own homes. The volunteers generally visit for 1.5 hours weekly. Once we receive your form our coordinators will find an appropriate match for your child. The time frame for finding a match depends on age, location, and flexibility.

Days and Times that are good for you in order of preference
Day (Excluding Sat) Time:
Day (Excluding Sat) Time
I would prefer to have a boy girl volunteer come to my house.
If you already have a volunteer coming to the house, please fill out the following:
Volunteer #1 Volunteer #2
I am happy with my current status of volunteers, but need to get re-started
The volunteers that come to my home need more guidance. Please call me at your earliest convenience to discuss further.
It is a pleasure to provide you with the Friends @ Home service. However, it is necessary for the parents/guardians to assume responsibility to oversee and supervise activities shared together with your child. It is equally important to inform the Friendship Circle Staff immediately with any concerns or issues that may occur. Please read the information below carefully and initial your consent.
I agree that a parent/guardian will be at my home at all times while the Friendship Circle volunteers are interacting with my child. Such parent/guardian will oversee and supervise all activities of my child and the volunteer
I understand that this program does not provide tutoring, babysitting, therapeutic, referral, clincial, psychological, social or medical services.
I understand that my teen volunteers are NOT permitted to drive or take my child to a location outside my hoe. If i wish to meet my volunteer at a different location, I may do so only:
  • With my volunteers consent
  • If I provide transportation to and from the location
  • If I remain with my child and volunteers throughout the duration of the Friends @ Home visit (if you are attending a Friendship Circle activity, you do not have to remain with your child and volunteer).
By submitting this form, I release the Friendship Circle, its providers, administrators and volunteers from any and all liability, damages, injuries or claims to property or persons for any accident, occurrence, or accident which may occur and which affects or involves the health, welfare or safety of my child during the course of the provision of such service by a Friendship Circle volunteer, staff member or administrator.
Name Date: