Child's Info Child's Name Birth Date / / Month Day Year Address City State Zip Phone Number Father's Info Name Occupation Cell Phone E-Mail Mother's Info Name Occupation Cell Phone E-Mail Additional Info Medical Info Emergency contact name (other than parent) Phone Cell Please list any medical conditions that we should be aware of: Please list any environmental, medicine or pet allergies: Please provide any information that may be helpful when interacting with your child: Programs Programs: Choose all programs for which you would like to participate View the 2013-14 Program Guide for Complete Schedule HERE Friends at Home Info: Time & Day of the Week set up on an individual basis, see below Sunday Circle Info: One Sunday a Month 1:00 - 3:00 PM See Program Guide for dates Holiday Circle Info: Seasonal, See program Guide for Dates & Locations Bowling Buddies Info: 6 Mondays, September 23 - October 28 4:45 - 5:45 PM Cooking Circle Info: 4 Tuesdays, November 12 - December 9 4:45 - 5:45 PM Life Skills Events Info: 4 Mondays, January 6 - February 10 4:45 - 5:45 PM After School Program Info: 4 Tuesdays, March 11 - April 8 4:45 - 5:45 PM If you chose Friends at Home, when would you like FC friends to come and visit your home? 1st choice Day of the week Select One Sunday Monday Tuesday Wednesday Thursday Friday Time PM AM 2nd choice Day of the week Select One Sunday Monday Tuesday Wednesday Thursday Friday Time PM AM Would you be interested in having the same volunteers or new volunteers Code of Conduct & Consent form In order for your child to participate in The Friendship Circle, the Code of Conduct and Consent Form must be read completely and signed. Download Code of Conduct and Safety Agreement HERE. (2 Pages) Then, return to this page to sign electronically. I have read the Code of Conduct completely and agree to all of its contents. I have read the Safety Consent Form completely and agree to all of its contents. Signature Application Date This page uses 128 bit SSL encryption to keep your data secure.
