Summer Circle 2023 Registration

- Staff members and volunteers have joined to provide everyone with a safe and fun experience!
- Participants who have potential behaviors that may cause harm to themselves or others, tendency to wander/run from a group or who needs help in the restroom, is welcome to attend with a parent or aid.
- VFC Does not administer medication if your child needs to take medicine between 9:30-3:00 they must be able to take on their own, or it can be brought to them by a parent/guardian.
- Please contact Chanie Baitelman with any questions! 8182625016 [email protected]
Participant's Info
Full Name*

First Name Last Name
Birth Date*

Month Day Year
Gender
Grade entering
Medical Information
Pediatrician*

First Name Last Name
Phone Number*

Area Code Phone Number
Insurance*
My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise*

YesNo
Is your child allergic to any medications? If yes, please explain*
Is your child allergic to any foods? If yes, please explain*
Are there any specific challenges we should be aware of?
Agreement:
I agree to release the Valley Friendship Circle and its providers and administrators, from all liabilities for any incident which affects the health, welfare and safety of my child during the provided transportation.
I agree to the Liability consent*

Yes
I give permission to The Valley Friendship Circle to transport my child to and from excursions while my child is in their care. I agree to release the Valley Friendship Circle and its providers and administrators, from all liabilities for any incident which affects the health, welfare and safety of my child during the provided transportation.
I accept the Transportation Consent. (By not agreeing to these terms, I am choosing to arrange transportation for my child to and from trips).*

Yes
2. Parents Information
Mothers Info:
Full Name*
Phone Number*

Area Code Phone Number

Address*

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

E-mail* Primary email
Marital Status

MarriedSingleDivorcedSeparated
Fathers Info:
Full Name*
Phone Number*

Area Code Phone Number

Address* Leave blank if same as above

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

E-mail* Primary email
Marital Status

MarriedSingleDivorcedSeparated
Child may be picked up from camp by:*

Name and Relationship
3. Emergency Information
Messages*

I woulld like to receive updates via what's app messages
Emergency Contact*

First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Date & Time

Month Day Year
at Hour Minutes
4. Payment Information

A $25 non-refundable registration fee per child applies as part of this registration.
Please select:*

$25 Registration fee
FFF Fee*

November 20-22 - $300Lunch Option - $15 per dayPer Day Option - $100
Please select which days:*

Monday Nov 20Tuesday Nov 21Wednesday Nov 22
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

City

State / Province

Postal / Zip Code

Country

Agreement*

I am signing up my child for Fall Friendship Fun and give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid.I give Valley Friendship Circle permission to photograph and videotape my children and use the photos and videos (without their names) for whatever the Summer Circle sees fit.
General comments
5. Terms and Conditions
- PARENTAL CONSENT: I hereby give consent for my child to participate in all activities of Valley Friendship Circle Fall Friendship Fun both on and off site, trips, transportation to and from trips etc., unless I advise you otherwise in writing.
- Limited Guardianship Approval: I hereby consent that CGI's directors - Rabbi _Yossi Baitelman____ & Mrs.Chanie Baitleman ____ be granted limited guardianship capabilities with regards to signing waivers on behalf of my child / children for trips specified in this year's camp schedule. (I do understand that I may still be asked to fill out waivers, as not all locations accept this consent)
- PAYMENT AND CANCELLATION: Payment terms are a $25.00 non-refundable deposit per camper to accompany registration.
- DISMISSAL OF Participant: Parent fully understands and agrees that the Valley Friendship Circle reserves the right to dismiss, in its sole discretion, any participant whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the fellow participants or who violates rules and regulations. In the event of dismissal, tuition will be refunded on a prorated basis less the $50.00 registration deposit.
- INDEMNIFY & HOLD HARMLESS: I further release and agree to indemnify and hold harmless Valley Friendship Circle (VFC) and its officers, servants or assignees from any liability concerning our child’s involvement in VFC and further agree that the use of any premises during the VFC Summer Circle day is made at the risk of the registrant.
- I have read and agree to all of the terms and conditions in this Application Form. I am including a non-refundable $25 registration deposit per camper along with submission of this form. I further agree to remit the full amount and other fees by Nov 20th.
Month Day Year
at Hour Minutes
Signature of Parent or Guardian*
Should be Empty:

Fall Friendship Fun 2023 Registration

Participant's Info

Medical Information

Agreement:

2. Parents Information

Mothers Info:

Fathers Info:

3. Emergency Information

4. Payment Information

5. Terms and Conditions

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