Child Application

Child's Full Name*

First NameLast Name

E-mail*

Gender*

MaleFemale

Birth Date

MonthDayYear

School*

Address*

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

Cell Number*

Area CodePhone Number

YES, I recieve text messages

Phone Number*

Area CodePhone Number

Programs of Interest*

FRIENDS AT HOMESUNDAY CIRCLEHOLIDAY PROGRAMSTWEEN MUSIC CIRCLE

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

TimeFirst Choice

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

TimeSecond 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?

YesNo

Which Program?

How did you hear about Valley Friendship Circle?

Father's Full Name*

First NameLast Name

Father's E-mail*

Father's Cell Number*

Area CodePhone Number

Mother's Full Name

First NameLast Name

Mother's E-mail

Mother's Cell Number*

Area CodePhone Number

Emergency Contact Name

First NameLast Name

Relationship to Child

Emergency Contact Number

Area CodePhone 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 NameLast Name

Doctor Number

Area CodePhone 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 CodePhone 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 [email protected] 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 activitiesI 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 [email protected] 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 controlledI, 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

MonthDayYear

Child's Information

Parents Information

Emergency and Medical Contact Information

Friends @ Home

Volunteer Club

Virtual Friendship Fun

Parent Support Circle

Friend to Friend

Social Circle