Age 3-12

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender*

MaleFemale

Address*

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

Home Phone*

Area CodePhone Number

School*

Grade*

Congregation*

Responsible Party

MomDad

Responsible Party's E-mail*

Father's Name

First NameLast Name

E-mail

Cell Phone

Area CodePhone Number

Occupation

Mother's Name

First NameLast Name

E-mail

Cell Phone

Area CodePhone 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 NameLast Name

Relationship to child*

Cell Phone*

Area CodePhone 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 NameLast Name

Phone Number*

Area CodePhone 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 NameLast Name

Cell Phone*

Area CodePhone 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 2022-23.*

Consent

(Please note that if you require financial assistance for any of the programs, please don't hesitate to contact us and we will gladly work with you.)

I would like my child to participate in the following programs:

Birthday Club - one Sunday a month (no fee) recommended until age 14- depending on the venue

Yes

Friends at Home - once a week throughout the school year (no fee)

Yes

Holiday Programs - seasonal

Yes

Torah Circle - two Sundays a month from 1:30-3:00pm at the Friendship Tent 10500 Burbank DR ($280 for 14 sessions)

Yes

Comments

Total

$0.00

I would like to pay today: Full amount$20.00 minimum $

Note: If you opt for partial payment, the balance will be divided up into equal parts and charged monthly. The partial payment option is only available if you are paying by credit card.

Payment*

Credit Card Check

Postal / Zip Code

Country

New Junior Participant Registration Form

Age 3-12

Participant's Information

Parent's Information

Medical & Emergency Information

Parental Agreement

Programs

Payment Information

More in this section