Adult Participant's Information Full Name* First Name Last Name Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Gender* Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Home Phone* Area Code Phone Number E-mail* School (if applicable) Is your child a client of a Regional Center* YesNo 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 InformationIn 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 ReleaseMy 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 HomeThe 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: 123456789101112 Hour001020304050 MinutesAMPM Day (Excluding Sat) Time: 123456789101112 Hour001020304050 MinutesAMPM Prefrence of volunteer to come to my house. Girl VolunteerBoy 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-startedThe 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) 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 RecognitionI 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.