Welcome to Friendship Circle! Your child is about to enter a circle of warm, loving friends who are so excited to include him/her in all of our events and programs. Your child will feel right at home, in a safe and welcoming environment that is open to everyone, in a place full of laughter and love. We can’t wait to have him/her join our circle of friends! Child Registration Form 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 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 Female Male 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 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 Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus 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 Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie 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 Lives with: Both parents Mom Dad Parents Information Mother’s Name* First Name Last Name Mother's Cell Number* Area Code Phone Number Mother's Email:* Mother's Occupation* Best way to be contacted* Call Text Message Whatsapp Email Father’s Name* First Name Last Name Father’s Cell Number* Area Code Phone Number Father's Email:* Father's Occupation* Best way to be contacted Call Text Message Whatsapp Email Parents’ Marital Status:* Married Divorced Other Please list one reference, who is not a relative.* Name Relationship Phone Number Background Information Help us get to know your child! What is your child’s primary mode of communication? (e.g. speaks words, speaks full sentences, hand gestures, picture board, etc.)* Is your child sensitive to sounds, touch, water, animals or anything else? If so, how can we help them through it? Are there any specific behaviors your child has that we should be aware of? Please specify. What are some things your child likes to do in his/her free time?* If your child is agitated, what are effective methods you have used to calm him/her down? If applicable, please list any allergies or medical concerns that we should be aware of, and their severity: Respite Service Agreement-Required It is the Friendship Circle’s pleasure to provide its services. However, it is necessary for the parents/guardians to assume responsibility to oversee activities shared together. By signing below, I agree to ensure that a parent/guardian will be home while volunteers are interacting with my child. I also agree to release the Friendship Circle, its providers and administrators from all liability from and incident which affects the health, welfare or safety of my child in the provision of such service. I permit my child’s photo to be used for publicity purposes:* Yes No Sign by entering your email* Comments Submit Should be Empty: This page uses TLS encryption to keep your data secure.
A look at numbers
225 families who have children with special needs benefit from our programs.
310 teenagers provide more than
20,000 friendship hours annually.