New Participant Registration Form

Full Name*

First Name Last Name

Birth Date*

Month Day Year

Gender*

Male Female

Address*

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

Home Phone*

Area Code Phone Number

School/ Employment*

Grade*

Congregation*

Responsible Party

Mom Dad

Responsible Party's E-mail*

Father's Name

First Name Last Name

E-mail

Cell Phone

Area Code Phone Number

Occupation

Mother's Name

First Name Last Name

E-mail

Cell Phone

Area Code Phone Number

Occupation

A. In case of an emergency when neither parent can be reached please provide the name of a person who will assume responsibility for your child.

Full Name*

First Name Last Name

Relationship to child*

Cell Phone*

Area Code Phone Number

B. If parents cannot be reached and emergency medical advice is required, permission is granted to the Friendship Circle staff to contact my child's physician.

Physician's Name*

First Name Last Name

Phone Number*

Area Code Phone Number

C. In case of a medical emergency where immediate medical care is necessary, I authorize the paramedics to take my child to the nearest hospital

Health Insurer*

Policy Number*

D. Additional medical information or comments

Allergies

Medications

Dietary Restrictions

Comments

I hereby give permission to the following person to pick up my child from Friendship Circle activities.

Full Name*

First Name Last Name

Cell Phone*

Area Code Phone Number

Relation to Child*

If my child participates in the Friends at Home program, I agree that a parent/guardian will be present in the home to supervise them.*

Consent

I permit my child's photo to be used for publicity purposes.*

Consent

Where applicable, I permit my child to be transported by the Friendship Circle to or from activities.*

Consent

I hereby release the Friendship Circle, its providers and administrators from ALL liability resulting from any incident which affects the health, welfare or safety of my child while participating in a Friendship Circle program for the year 2020-21*

Consent

Please choose the programs you would like to be apart of

virtual friends at home social distant friends at home social distant carnivals and programs garden birthday party for your child YAD (young adult division) Zoom YAD social distant meet ups parent support groups moms/dads night in virtual Torah Circle

Comments

New Participant Registration Form

New Participant's Information

Parent's Information

Medical & Emergency Information

Parental Agreement

Programs

More in this section