Child Registration - Friendship Circle

Family Registration Form

My Child's Information
Child's Full Name
Child is Called By
Birthday (dd/mm/yyyy)
Age
Street Address
City, State, Zip
Home Phone
School
Grade Entering (Sep. 2011)

Parent's Information
Father's Name
Father's Email
Mother's Name
Mother's Email
Work Phone
Cell Phone
Parent's Status	Married Divorced Single
Child lives with
How can you best be reached when your child is in our care?
Religion

Medical and Emergency Information
A. In case of emergency, when neither parent can be reached, please give the names of a person who will take responsibility for your child.
Name
Home Phone
Cel Phone
Relationship
Address
City
B. If parents can not be reached, and emergency medical advice is needed, permission is given to The Friendship Circle of Cleveland staff to phone my child's doctor.
Doctor
Phone
Address
City
C. Further Medical Information - Medical Concerns/Diagnosis
Allergies
Medications
Other Medical Information

I would like to sign my child up for:

Friends at Home
	I would like to sign up for Friends at home (weekly basis)

	First Choice Day of Week
	First Choice Time
	Second Choice Day of Week
	Second Choice Time

Sunday Circle
	I would like to sign up for Sunday Circle (monthly basis)

Parental Consent

It is a pleasure to provide for you and your child. However, it is necessary for the parents/guardians to assume responsibility to oversee activities shared together.

I agree that a parent/guardian will be at my home while the volunteers are interacting with my child for Friends @ Home. By checking this box, I release the Friendship Circle, its providers and administrators, from ALL liability for any incident which affects the health, welfare, or safety of my child in the provision of a Friendship Circle program for the year 2011/201.

I permit my child’s photo to be used for publicity purposes.

I permit my child to be transported to and from excursions while he/she is in their care.