Adult Registration

Full Name*

First Name Last Name

Birth Date

Month Day Year

Gender

Phone Number

E-mail*

I would like to receive news and updates by email

Address

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

Are You A Client Of A Regional Center?*

YesNo

Would You Like To Learn More About The Regional Center?

YesNo

Religion

Synagogue Affiliation *If Applicable

Occupation

Special Need*

Are you a Legal Caregiver?

YesNo

Full Name

First Name Last Name

Relationship to Participant

MotherFatherLegal Guardian/Other

Phone Number

E-mail

Same Address as Participant's Information

Address

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

Occupation

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

Does you need supervision and support during bathroom routines? (If yes, please explain)

Describe your 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 you like? For example: Running, jumping drawing, painting, sports, animals, music etc.

What are some things that upset you? For example: Transitions, loud noises, new people etc.

Are you able to drive/have reliable transportation?*

YesNo

In case of an emergency, when you are unable to make decisions, please provide the name of someone who will take responsibility for you:

Full Name*

First Name Last Name

Relation*

Phone Number*

Hospital Affiliation

Medical Concerns/Diagnosis

Medications Taken Regularly*

Medicinal/Environmental/Pet Allergies

Dietary Restrictions

I or authorized representative, I hereby give consent to Friendship Circle that I will 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 myself, 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 individual named above. I hereby give my permission that paramedics can transport me 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 agreeing by my signature below.*

I give permission for my photo to be used for Friendship Circle marketing/publicity purposes (i.e., brochures, newspapers, website, social channels, etc.)

Full Name*

First Name Last Name

Date*

Month Day Year

Signature*

Adult's Information

Legal Caregiver Information

Programs To Get Involved In

Help Us Get To Know You a Little Better

Additional Information

Emergency Medical Information

Medical and Emergency Release

Signature