Young Adult Sign Up Form (18 & over)

I am filling this out for:*

Myself

My Child

Young Adult Information

Name*

First Last

Gender*

Do you/your child have a disability?*

Yes

No

Email*

Phone*

Phone Type*

Best Way to Contact*

Young Adult Information

Home Address*

Street Address Address Line 2 City State ZIP Code

Is your home address the same as your mailing address?*

Yes, my mailing address is the same as my home address

No, my mailing address is different than my home address

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

School

High School Graduating Year (if applicable)

Synagogue Affiliation (if applicable)

I am:*

Over 18 and Independent

Over 18 and Require Legal Guardian

My child is:*

Over 18 and Independent

Over 18 and Require Legal Guardian

Family Information

Parent/Gaurdian #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 young adult?*

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/Gaurdian #2

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Gender

Parent/Guardian #2 Email

Parent/Guardian #2 Phone Type

Parent/Guardian #2 Phone

Best Way to Contact Parent/Guardian #2

Does Parent/Guardian #2 have the same address as the young adult?

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

Age

Any Needed Support or Accommodations?

Reference Information

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

Reference Name*

First Last

Reference Phone*

Relationship*

Safety & Health Information

Emergency Contact Name*

First Last

Emergency Contact Phone*

Emergency Contact Relationship*

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

Do you/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/your child's interests/hobbies?

What are some of your/your child's strengths?

What are some of your/your child's coping strategies?

Additional Notes/Comments

Service Agreement

I (Participant or Parent/Guardian) hereby give permission to the staff of The 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 The 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 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 (Participant or Parent/Guardian) permit my/my child’s photograph and video to be used for publicity purposes – please contact 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 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:*

Young Adult Information

Young Adult Information

Family Information

Parent/Gaurdian #1

Family Information

Parent/Gaurdian #2

Family Information

Reference Information

Safety & Health Information

Getting to Know You

Programming Information

Service Agreement