CHILD APPLICATION ( * designates required fields)

FIRST NAME *: LAST NAME *:
GENDER: MALE FEMALE AGE:
DATE OF BIRTH *: SCHOOL:
ADDRESS *: CITY *:
STATE: ZIP CODE:
HOME PHONE *: CELL PHONE *:
E-MAIL ADDRESS *:

YES, I recieve text messages.

** Please provide a current-working email, as we send out event invitations and information primarily through email.

PARENTS' INFORMATION
FATHER'S NAME: MOTHER'S NAME:
FATHER'S MOBILE: MOTHER'S MOBILE:
FATHER'S E-MAIL: MOTHER'S E-MAIL:

PROGRAMS OF INTEREST (You can check as many as you'd like):

FRIENDS AT HOME SUNDAY CIRCLE HOLIDAY PROGRAMS

TWEEN MUSIC CIRCLE

For those who checked box "FRIENDS AT HOME"

1) When would you like a volunteer to come to you home?

FIRST CHOICE: SECOND CHOICE:

2) What does your child enjoy doing most?

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

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

5) Have you been to a VFC program? YES NO

If YES, which one?

6) How'd you hear about the VALLEY FRIENDSHIP CIRCLE?

QUESTIONS OR COMMENTS:

MEDICAL EMERGENCIES

A. Emergency contact, in case neither parent can be reached.

NAME *:

 RELATIONSHIP TO CHILD *:
PHONE *:
ADDRESS: CITY/STATE/ZIP:
B. 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 *:

PHONE *:
ADDRESS: CITY/STATE/ZIP:
DOCTOR'S HOSPITAL AFFILIATION:
C. 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: NUMBER:



D. Food allergies:

E. Additional medical information or comments:

I permit my child's photos to be used for publicity purposes to assist the Valley Friendship Circle.

As a Parent of a special needs child of Friendship Circle:
1) I understand that as part of the Friends@Home program, the Valley Friendship Circle will match my child with two teenage volunteers.
2) 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
3) I agree to respect the privacy of all participants of the VFC and to keep personal information confidential.
4) I understand and agree to, at all times have at least one parent/guardian “on premises” during the entirety the Friends@Home visitation program
5) 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
6) 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
7) 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’s Signature: Date: