Children & Teen Sign Up Form (17 & Under)

Child/Teen Information

This is all about your child’s info. We’ll ask for your details later!

Name*

First Last

Gender*

Does your child have a disability?*

Yes

No

Email*

Phone*

Phone Type*

Best Way to Contact Child/Teen*

Child/Teen Information

Home Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Upcoming Bar/Bat Mitzvah Date (if applicable)

School*

High School Graduating Year (if applicable)

Synagogue Affiliation (if applicable)

Family Information

Parent/Guardian #1

Parent/Guardian #1 Name*

First Last

Parent/Guardian #1 Gender*

Parent/Guardian #1 Email*

Parent/Guardian #1 Phone*

Parent/Guardian #1 Phone Type*

Best Way to Contact Parent/Guardian #1*

Does Parent/Guardian #1 have the same address as the child/teen?*

Yes, we live at the same address

No, we live at a different address

Parent/Guardian #1 Address*

Street Address Address Line 2 City State ZIP Code

Family Information

Parent/Guardian #2

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Gender

Parent/Guardian #2 Email

Parent/Guardian #2 Phone

Parent/Guardian #2 Phone Type

Best Way to Contact Parent/Guardian #2

Does Parent/Guardian #2 have the same address as the child/teen?

Yes, we live at the same address

No, we live at a different address

Parent/Guardian #2 Address

Street Address Address Line 2 City State ZIP Code

Family Information

Marital Status of Parent/Guardian(s):

Please list all additional members of your household.

If any members of your household need additional support or accommodations we should be aware of, please be sure to include them below.

Name

Relationship

Date of Birth

Any Needed Support or Accommodations?

Reference Information

We recommend listing teachers, coaches, or employers as references.

Reference Name*

First Last

Reference Phone*

Relationship to Child/Teen*

Safety & Health Information

Emergency Contact Name*

(Cannot be parent/guardian)

First Last

Emergency Contact Phone*

(Cannot be parent/guardian)

Emergency Contact Relationship*

(Cannot be parent/guardian)

Please list all of your child’s allergies (If none, type "none")*

Does your child have seizures? If so, please describe onset signs of a seizure*

Are there any health or medical conditions we should be aware of? If so, please describe*

Additional Notes/Comments about safety and health information

Getting to Know You

What are some of your child's interests/hobbies?

What are some of your child's strengths?

What are some of your child's coping strategies?

Additional Notes/Comments

Service Agreement

I (Parent/Guardian) hereby give permission to the staff of The Friendship Circle to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.

I (Parent/Guardian) hereby release The Friendship Circle, its providers and administrators, from all Liability for any incident which affects the health, welfare, or safety of (Child) in the provision of such service.

I (Parent/Guardian) permit Friendship Circle to use my contact information for phone, text and email communications. Msg & data rates apply – please contact Friendship Circle staff to be removed from messaging lists.

I (Parent/Guardian) permit my child’s photograph and video to be used for publicity purposes – please contact Friendship Circle staff to be removed from publicity lists.

I (Parent/Guardian) permit my child’s name to be printed on select Friendship Circle materials – please contact Friendship Circle staff to be removed from print lists.

Signature*

Please include the email you would like to have a copy of this form sent to:*

Children & Teen Sign Up Form (17 & Under)

Child/Teen Information

Child/Teen Information

Family Information

Parent/Guardian #1

Family Information

Parent/Guardian #2

Family Information

Reference Information

Safety & Health Information

Getting to Know You

Programming Information

Service Agreement