Friendship Circle Registration

Your Child's Information

Child's Full Name

First Name Last Name

Birth Date

Month Day Year

Gender

Male Female

Address

Street Address
Street Address Line 2
City	Province
Postal Code	Country

School Attending

Grade

Mother's Information

Mother's Full Name

First Name Last Name

Home Phone Number

Area Code Phone Number

Work Phone Number

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Occupation (optional)

E-mail

Best way to reach me

Home Phone Work Phone Cell Phone E-mail

Father's Information

Father's Full Name

First Name Last Name

Home Phone Number

Area Code Phone Number

Work Phone Number

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Occupation (optional)

E-mail

Best way to reach me

Home Phone Work Phone Cell Phone E-mail

Parent's Status

Married Divorced

If divorced, child lives with

Mother Father Other

Medical Information

Emergency Contact (other than parents)

Relationship

Emergency Contact Number 1

Area Code Phone Number

Emergency Contact Number 2

Area Code Phone Number

What are your child's special needs?

Please list any allergies or medical conditions that we should be aware of

Siblings

Full Name

First Name Last Name

Birth Date

Month Day Year

School Attending

Full Name

First Name Last Name

Birth Date

Month Day Year

School Attending

Full Name

First Name Last Name

Birth Date

Month Day Year

School Attending

Additional Information

What languages does your child speak?

What are your child's favourite activities?

What makes your child upset?

Does your child occasionally exhibit any of the following behaviours?

Please specify any other behaviours if not listed above

What is the best method of handling the situation?

How does your child communicate his/her needs or thoughts?

Are there any activity restrictions for your child? (If so, please specify)

What else should we know about your child?

How did you hear about the Friendship Circle?

Release

I/We release the Friendship Circle, its providers and administrators, from all liability for any incident which affects the health, welfare or safety of my child in the provision of such service.

I allow my child's photos and videos to be used for any and all Friendship Circle publicity purposes.

Yes No

Form Completed by

First Name Last Name

Relation to Child

Mother Father Legal Guardian

Date of Submission

Month Day Year

at Hour Minutes

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