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I am:*
My child is:*

Basic Info

Young Adult Information

Please provide your child’s information. We’ll ask for your details later!

Name*
MM slash DD slash YYYY

While we are a Jewish organization, we welcome friends from all walks of life. It is helpful for us to understand your connection to the Jewish community.

Please select one of the following:*
If you have a synagogue affiliation, please share it here or write n/a.
Does your child have a disability?*
Do you have a disability?*

Contact Info

Home Address*
County*
Is your home address the same as your mailing address?*
Mailing Address*

Parent/Guardian #1

Parent/Guardian #1 Name*
Does Parent/Guardian #1 have the same address as the young adult?*
Parent/Guardian #1 Address*

Parent/Guardian #2

Only 1 Guardian
Parent/Guardian #2 Name
Does Parent/Guardian #2 have the same address as the young adult?
Parent/Guardian #2 Address

Family Info

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

Reference Information

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

Reference Name*

Emergency Contact

Emergency Contact Name*

Allergies

Do you/your child have food allergies?*
List food allergies:*
Do you/your child have allergies to medications and/or other items?*
List medication and other allergies:*

Seizures

Do you have seizures?*
Does your child have seizures?*

Medical Information

Getting to Know You

Getting to Know Your Child


For Reporting Purposes (Optional):
Our donors and grant funders are deeply invested in understanding the diverse community we serve and the variety of diagnoses represented. Sharing this information helps us communicate the scope of our impact—but it does not affect the individualized, person-centered approach we take with your child in any of our programs.

If you are comfortable sharing, your response will be used for reporting purposes only and will be kept anonymous.

Optin
Please select any that apply (you may choose more than one):

Programming Information

Which programs are you interested in?*
How did you hear about Philly Friendship Circle?

Service Agreement

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

I (Participant or Parent/Guardian) hereby release Philly Friendship Circle, its providers and administrators, from all liability for any incident which affects the health, welfare, or safety of myself/my child in the provision of such service.

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

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

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

Consent*

Philly Friendship Circle connects teens and young adults to youth with special needs and their families through a full range of social offerings. Inspired by the power of genuine friendships, our youth cultivate understanding, kindness and responsibility while ensuring a caring and inclusive community.

www.phillyfriendshipvirtual.com
215-574-1765
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© 2021 Philly Friendship Circle. All Rights Reserved.

Founded by Chabad-Lubavitch