Child Application

Child's Full Name*

First Name Last Name

E-mail*

Gender*

Male Female

Birth Date

Month Day Year

School*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Number*

Area Code Phone Number

YES, I receive text messages

Phone Number*

Area Code Phone Number

Programs of Interest*

FRIENDS AT HOME SUNDAY CIRCLE HOLIDAY PROGRAMS SOCIAL CLUB SHABBAT-IN-A-BOX GROUP PROJECT MIND BODY & SOUL SOCIAL SKILLS CIRCLE 2 PART SESSION- $85 MIND BODY & SOUL SOCIAL SKILLS CIRCLE INDIVIDUAL SESSION - $45 WINTER CAMP -$389 DEC 26-29

When would you like a volunteer to come to you home? First Choice

Time First Choice

When would you like a volunteer to come to you home? Second Choice

Time Second Choice

What does your child enjoy doing most?

Is there anything in particular that your child does not like doing?

4) Is there anything we need to know about your child?

Have you been to a VFC program?

Yes No

Which Program?

How did you hear about Valley Friendship Circle?

Father's Full Name*

First Name Last Name

Father's E-mail*

Father's Cell Number*

Area Code Phone Number

Mother's Full Name

First Name Last Name

Mother's E-mail

Mother's Cell Number*

Area Code Phone Number

Emergency Contact Name

First Name Last Name

Relationship to Child

Emergency Contact Number

Area Code Phone Number

Emergency Contact Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

If parent cannot be reached and emergency medical advice is needed, permission is given to the Valley Friendship Circle staff to phone my child's doctor.

Doctor Name

First Name Last Name

Doctor Number

Area Code Phone Number

Hospital Affiliation

Doctor Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

In case of medical emergency requiring immediate care, I authorize the Valley Friendship Circle staff and/or paramedics to take my child to the nearest hospital to receive medical care.

Health Insurance Name

Health Insurance Number

Area Code Phone Number

Food Allergies

Additional medical Information or Comments

Consent*

I permit my child's photos to be used for publicity purposes to assist the Valley Friendship Circle. I understand that as part of the Friends@Home program, the Valley Friendship Circle will match my child with two teenage volunteers. I understand that it is necessary for me as parent(s)/guardian(s) to assume full oversight and supervision responsibilities with respect to all Valley Friendship Circle activities I agree to respect the privacy of all participants of the VFC and to keep personal information confidential. I understand and agree to, at all times have at least one parent/guardian “on premises” during the entirety the Friends@Home visitation program. I agree that the parent/guardian takes full responsibility for everything that transpires during the visit and exempts the Valley Friendship Circle from any responsibility. I give my child permission to participate in the Valley Friendship Circle. I understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct as set forth in above, as it may be modified from time to time. I understand that this local Valley Friendship Circle is an independent owned, operated and controlled I, myself and on behalf of my child, release the Valley Friendship Circle and its employees, directors, officers and volunteers as well as all other organizations associated with the VFC from any and all claims or liability arising out of this participation.

Parent/Guardian Signature

Date

Month Day Year

Optional Donation

$

Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Child's Information

Parents Information

Emergency and Medical Contact Information

Friends @ Home

Volunteer Club

Virtual Friendship Fun

Parent Support Circle

MIND BODY & SOUL

Social Circle