Your Child's Information
First Name * Last Name *
Birthday * Gender *
Address * City *
State * Zip *
Home Phone * Email *
School * Religion *
Disability Grade *
How did you find out about Friendship Circle?
Parent Information
Mother's Name * Father's Name *
Mother's Email * Father's Email *
Mother's Cell * Father's Cell *
Mother's Occupation Father's Occupation
Parent's Marital Status If Divorced, Lives With
Help Us Get to Know Your Child a Little Better
Does your child need supervision and support during bathroom routines? (If yes, please explain)
Describe your child's strengths and weaknesses in the areas of social, cognitive , physical and communicative domains
Any special fears of which we need to be aware? For example: Water, bright lights, animals etc.
Any personality conditions of which we need to be aware? For example: Shyness, hiding, wandering away, tantrums etc.
Are there any special things your child likes? For example: Running, jumping drawing, painting, sports, animals, music etc.
What are some things that upset your child/ For example: Transitions, loud noises, new people etc.
 
Medical Information
In case of an emergency, when neither parent can be reached, please provide the name of someone who will take responsibility for your teen
Name * Relation *
Phone * Cell Phone *
Is this person allowed to pick up your child?
Medical Insurance Carrier
Policy Number * Doctor's Name *
Doctors Office Number * Hospital Affiliation *
Medical Concerns/Diagnosis
Medications Taken Regularly *
Any activities that your child should not participate in due to a limitation or medical condition *
Date of last tetanus shot (if known)
Medicinal/Environmental/Pet Allergies
Dietary Restrictions
Parental Medical and Emergency Release
My son/daughter has my permission to attend Friendship Circle events. I agree not to hold Friendship Circle liable for ay accident, loss, or theft that may occur during the course of an event. I hereby give my permission to the physician selected by The Friendship Circle to hospitalize, and/or secure necessary treatment or anesthesia for my child, as named above, in the event that I cannot be reached in an emergency. I hereby give my permission that paramedics can transport my child to the nearest hospital, if necessary. I have indicated any pertinent medical information above. I agree to the terms and conditions of this application. Additionally I am initialing below that I am agreeing to by my signature below.
I hereby give my child permission to participate in all activities planed by Friendship Circle (unless stated above) *
I hereby give permission to administer the medications to my child, upon my request as per written instructions (non-emergency) *
I give permission for my child's photo to be used for publicity purpose (i.e., brochures, newspapers, website, etc.) *
 
Programs To Get Involved In

Friends at Home

The Friends @ Home program gives children the chance to get to know their volunteers in an environment that they are most comfortable - their own homes. The volunteers generally visit for 1.5 hours weekly. Once we receive your form our coordinators will find an appropriate match for your child. The time frame for finding a match depends on age, location, and flexibility.

Days and Times that are good for you in order of preference
Day (Excluding Sat) Time:
Day (Excluding Sat) Time
I would prefer to have a boy girl volunteer come to my house.
 
If you already have a volunteer coming to the house, please fill out the following:
Volunteer #1 Volunteer #2
I am happy with my current status of volunteers, but need to get re-started
The volunteers that come to my home need more guidance. Please call me at your earliest convenience to discuss further.
 

Group Activities and Programs (Check all that you would like to sign up for/receive information about)

Sunday Circle: Join us for 2 hours of fun and entertainment with a young child with special needs. At each Sunday Circle, you will join your buddy in an art class, play time and music. We meet once a month from 2:00 to 4:00 pm at Bonita Creek Park, 3010 La Vida, Newport Beach, CA. (See calendar for specific dates.)

Young Adult Circle: Join us for 2 hours of fun at Young Adult Circle, where you and your buddy will learn life skills useful for an everyday basis! Our program includes everyday activities, social skills, cooking, shopping, adventures and entertainment, which simultaneously incorporate independence, laughter, and friendship that make for great memories. We meet one Sunday per month from 5:00 to 7:00 pm - see calendar for dates and location.

Basketball Buddies: Basketball Buddies is for ages 8 and up. Volunteers and kids can be with each other while playing a sport they love. This program allows for the kids to be part of a team, and to learn the fundamentals of Basketball. We meet one Sunday a month from 11:00 am to 1:00 pm - see calendar for dates and location.

Soccer Stars: Soccer Stars pairs teen volunteer soccer players with kids, teens, and adults to teach them the fundamentals of soccer. They get to be part of a team and they play a scrimmage game each session. No prior experience is necessary to participate.

Hangin' With Friends: This program is for adults with special needs and volunteers 15+. This program offers entertainment and fun activities that are age appropriate for our young adults and provide them with even more opportunities to make new memories with their friends. See calendar for specific dates.

Winter/Summer Camp: Join us for an experience that will last a lifetime! At the FC Winter/Summer Camps you will transform your vacation as well as the vacation of a child with special needs into an exciting camp experience with fun-filled activities, games, sports and field trips. We meet one week at the beginning of the Summer and one week during Winter vacation.

 

Evening of Recognition

I agree that I will attend the Friendship Circle Evening of Recognition each year. I understand that my attendance is vital in showing appreciation for the volunteer(s) who spend time with my child and that my presence is critical to the success of the program. Please initial to confirm*:

 

 
Name * Date: *