Adult Participant's Information Full Name* First Name Last Name Birth Date* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Gender* Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Home Phone* Area Code Phone Number E-mail* School (if applicable) Religion Disability* Grade How did you find out about Friendship Circle?* Parent Information (if applicable) Mother's Name First Name Last Name Mother's Email Mother's Cell Area Code Phone Number Mother's Occupation Father's Name First Name Last Name Father's Email Father's Cell Area Code Phone Number Father's Occupation Parent's Marital Status If Divorced, Child Lives With Help Us Get to Know You/Your Child a Little Better Does you/your child need supervision and support during bathroom routines? (If yes, please explain) Describe your/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 they/you like? For example: Running, jumping drawing, painting, sports, animals, music etc. What are some things that upset you/them, 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 Full Name* First Name Last Name Relation* Phone Number* Area Code Phone Number Cell Phone* Area Code Phone Number Medical Insurance Carrier Policy Number* Doctor's Name* Doctors Office Number* Area Code Phone Number Hospital Affiliation* Medical Concerns/Diagnosis Medications Taken Regularly* Any activities that they 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 any accident, loss, or theft that may occur during the course of an event. I hereby give my permission to the physician selected by 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 permission for them to participate in all activities planned by Friendship Circle (unless stated above)* I hereby give permission to administer the medications to them, upon my request, as per written instructions (non-emergency)* I give permission for their photo to be used for publicity purpose (i.e., brochures, social media, 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: 1 2 3 4 5 6 7 8 9 10 11 12 Hour 00 10 20 30 40 50 Minutes AM PM Day (Excluding Sat) Time: 1 2 3 4 5 6 7 8 9 10 11 12 Hour 00 10 20 30 40 50 Minutes AM PM Prefrence of volunteer to come to my house. Girl Volunteer Boy Volunteer 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.) Yes 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 - check your email for dates and location. Yes Basketball Buddies: Basketball Buddies is for ages 8+. 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 12:30 pm - check your email for dates and location. Yes Tennis: Tennis is for ages 10+. Volunteers coaches teach the kids the sport of tennis. This program allows for the kids to learn a new sport they can play with their family and friends. We meet one Sunday a month from 11:00 am to 12:30 pm - check your email for dates and location. Yes 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. We meet one Sunday a month from 2:00 to 3:00 pm - check your email for dates and location. Yes Hangin' With Friends: This program is for young 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. Check your email for specific dates. Yes Winter/Summer Camp: Join us for an experience that will last a lifetime! At Friendship Circle camps, your child's vacation will be transformed with exciting field trips and fun-filled activities, games, sports and arts. We meet one week at the beginning of the Summer and one week during Winter vacation. Yes 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:* Full Name* First Name Last Name Date* Month Day Year Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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