Printed from FCMD.org

Teen Registration Form

Age 13-17

  • Participant's Information

  • Parent's Information

  • Medical & Emergency Information

  • 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.

  • 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.

  • 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

  • D. Additional medical information or comments

  • Parental Agreement

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

  • Programs

  • (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:

  • Payment Information

  • $0.00

    I would like to pay today:
  • 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.

  •   
    Credit Card
    payable to Friendship Circle and mail to:
    11621 Seven Locks Road
    Potomac, MD 20854
    Billing Address
  • Should be Empty:
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