Child: Sign Us Up! - The Merrin-Bienenfeld Friendship Circle

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FCStonyBrook.com » Kids Programs » Child: Sign Us Up!

Friendship Circle Registration

Your Child

Child's Name:*

Gender:*

Month

Day

Year

Date of Birth :*

Age:*

Address:*

City:*

Postal Code:*

Home Phone :*

School:*

Grade:*

Religion:*

Parents

Father's Name:*

Father's Cellphone:*

Work Phone:

Father's E-mail:*

Occupation:

Mother's Name:*

Mother's Cellphone:*

Work Phone:

Mother's E-mail: *

Occupation:

Parent's Status:*

Married

Divorced

Child living with:

Medical Information

Emergency Contact Name (other than a parent):*

Phone:*

Relationship:*

Cellphone:*

What are your child's special needs?*

Please list any allergies or medical conditions
we should be aware of:*

Siblings

Name:

School:

Month

Day

Year

Date of Birth :

Age:

Name:

School:

Month

Day

Year

Date of Birth :

Age:

Name:

School:

Month

Day

Year

Date of Birth :

Age:

Additional Information

What language does your child speak? *

What are your child's favorite indoor activities?*

Favorites outdoor activities?*

What makes your child happy?*
(Special toys, special activities)

What makes your child upset?*

Does your child occasionally exhibit any of the following behaviors?*

Biting	Cursing
Grabbing	Hitting
Kicking	Pulling Hair
Other:

How does your child communicate
his/her needs and thoughts?*

Are there any activity resctrictions for your child?*

What else should we know about your child?*

Friends @ Home

When would you like the volunteers to come and visit your home?

1st choice

Day of the week:

Time:

2nd choice

Day of the week:

Time:

Do you prefer having:

The same volunteers as last year, if available

New volunteers

It is our pleasure to provide you with our Friends at Home service. However it is necessary for parent/guardian to assume responsibility to oversee activities shared together.

I/We agree that a parent or legal guardian will be home at all times while volunteers are interacting with my/our child.

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 such service.

I permit my child’s photos to be used for Friendship Circle publicity purposes.

Please check off programs your choices:

Friends @ Home

Bowling League

Sports Night (New Program to begin shortly)

Birthday Club

Holiday Programs

Mom's Night Out