Child Registration

*If you a registering more than one child, you will need to submit an additional form per child registration.

Full Name*

First Name Last Name

Birth Date

Month Day Year

Gender

Address

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

E-mail

School

Grade

Is Your Child A Client Of A Regional Center?*

YesNo

Would You Like To Learn More About The Regional Center?

YesNo

Religion

Child's Special Need*

Full Name*

First Name Last Name

Relationship to Child*

MotherFatherLegal Guardian/Other

Phone Number*

E-mail*

Same Address as Child's Information

Address*

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

Occupation

Religion

Synagogue Affiliation *If Applicable

Parent's Marital Status

If Divorced, Child Lives With

Additional Parent Information:

Full Name

First Name Last Name

Relationship to Child

MotherFatherLegal Guardian/Other

Phone Number

E-mail

Same Address as Child's Information

Address

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

Occupation

Religion

Synagogue Affiliation *If Applicable

Programs I'm Interested In* *For More Details, Check Out Our Program Listing On Our Website, Under The Programs Tab.

Assisting with FC Future EventsCommunity Day: Programming For The Whole San Diego CommunityFamily Holiday EventsFriendship Dojo: Adaptive KarateFriends @ Home: A Home "Hangout" With A VolunteerLunch & Learn: Parent Support GroupShooting Stars: Dance and Art ClassSports Stars: Adaptive Sports ClassSunday Circle: Hebrew School For All!

Are you able to drive your child to or from your home?

To

From

Other

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.

In case of an emergency, when neither parent can be reached, please provide the name of someone who will take responsibility for your child:

Full Name

First Name Last Name

Relation

Phone Number

Is this person allowed to pick up your child?

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)

Month Day Year

Medicinal/Environmental/Pet Allergies

Dietary Restrictions

As the parent or authorized representative, I hereby give consent to Friendship Circle that my son/daughter has my permission to attend Friendship Circle events. I agree not to hold Friendship Circle liable for any accident, loss, or theft that may occur during the course of an event. I hereby give my authorization 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. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child named above. 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 agree to the terms and conditions of this application. Additionally, I am agreeing by my signature below.*

I hereby give my child permission to participate in all activities planned 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 marketing/publicity purposes (i.e., brochures, newspapers, website, social channels, etc.)

Full Name

First Name Last Name

Date

Month Day Year

Signature

I would like to receive news and updates by email

Your Child's Information

Parent's Information

Additional Parent Information:

Programs To Get Involved In

Additional Information

Help Us Get To Know Your Child a Little Better

Emergency Medical Information

Parental Medical and Emergency Release

Signature