2020-21 Registration

Full Name*

First NameLast Name

Gender*

MaleFemale

Birth Date*

MonthDayYear

Lives with*

Both parentsMomDadOther

If lives with "other," please specify here:

School Name*

Grade*

Allergies

Are you a returning applicant?*

YesNo

Mother's Name*

First NameLast Name

Home Number*

Area CodePhone Number

Cell Number

Area CodePhone Number

Work Number

Area CodePhone Number

E-mail*

Occuption*

Address*

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

Father's Name*

First NameLast Name

Home Numberif different than above

Area CodePhone Number

Cell Number

Area CodePhone Number

Work Number

Area CodePhone Number

E-mail*

Occupation*

AddressIf different than above

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

What is your child's primary mode of communication*

Is your child sensitive to sounds, touch, water, animals or something else? If so, how can we help them through it?*

Are there any specific behaviors your child has that we should be aware of?

Does anything else upset your child?

Are you looking for your child to be matched with a Volunteer for the 'Friends at Home' Program?

YesNo

Diagnosis

Medications

Any medical concerns to be aware of

Any activities your child should not participate in due to limitation or medical condition

Emergency Contact Name*

Emergency Contact Number*

Area CodePhone Number

Emergency Contact Cell Number

Area CodePhone Number

Relationship to Child*

Does this person have permission to pick up your child?*

YesNo

Sibling 1 Name

Sibling 1 Age

Sibling 2 Name

Sibling 2 Age

**Prior to my child's participation in the Friendship Circle, I will read, agree to and sign the FC Waiver and Permissions Form found on the registration page and will return the completed waiver.

Signature*

I understand typing my name here will be considered the same as my legal signature.

Date of Application

MonthDayYear

How did you hear about The Friendship Circle?

Ariella's NY Friendship Circle

New York Friendship Circle Family Registration

Participant Information

Parent's Information

Help us get to know your child

Medical and Emergency Information

Sibling Information