Child's Full Name*
First Name Last Name
Child's Gender*
Child's E-mail (Write NONE if your child does not have an email address.)*
Child's Cell Phone Number (Write 000 in both fields if your child does not have a cell phone number)*
Child's Home Phone Number (Write 000 in both fields if your child/household does not have a home phone number.)*
Best way to contact your child
Phone Call
Text Message
Email
Child's Home Address*
Child's Birth Date*
Upcoming Bar/Bat Mitzvah date (if applicable)
School (if applicable)
Synagogue Affiliation (If Applicable)
Parent/Guardian 1 Full Name*
First Name Last Name
Parent/Guardian 1 Gender*
Parent/Guardian 1 E-mail*
Parent/Guardian 1 Cell Phone Number*
Parent/Guardian 1 Home Phone Number (Complete IF DIFFERENT than child's home phone number)
Best way to contact Parent/Guardian 1*
Phone Call
Text Message
Email
Is Parent/Guardian 1 Address DIFFERENT than child's address?*
YES, has different address than child
NO, has same address as child
Parent/Guardian 1 Address
Parent/Guardian 2 Full Name
First Name Last Name
Parent/Guardian 2 Gender
Parent/Guardian 2 E-mail
Parent/Guardian 2 Cell Phone Number
Parent/Guardian 2 Home Phone Number (Complete IF DIFFERENT than child's home phone number)
Best way to contact Parent/Guardian 2
Phone Call
Text Message
Email
Is Parent/Guardian 2 Address DIFFERENT than child's address?
YES, has different address than child
NO, has same address as child
Parent/Guardian 2 Address
Marital Status of Parent/Guardian(s):*
Reference Full Name (Reference can NOT be a Parent or FC Staff Member)*
First Name Last Name
Reference Phone Number*
Reference E-mail*
Relationship
Emergency Contact Full Name (Must be Non Parent )*
First Name Last Name
Emergency Contact Phone Number (Must be Non Parent )*
Please list all of your child's allergies.*
Does your child have seizures? If so, please describe onset signs of a seizure.*
Are there any medical conditions we should be aware of? If so, please describe medical conditions.*
Additional Notes/Comments about safety and health information
Which sensory input is your child sensitive to?
Which behaviors should we be aware of?
How does your child communicate?
How does your child re-focus?
How does your child respond to touch?
Additional Notes/Comments about behavior information
What are some of your child's interests/hobbies?
What are some of your child's strengths?
What are some of your child's coping strategies?
Additional Comments/Notes on personal information
Which Programs are you interested in?*
Would you like to be added to our FC family Listerv?*
What information would you like included in the parent directory? (Check all that apply. We recommend including all this information.)
Is there any additional information or notes that you would like included in the parent directory?
How did you hear about Friendship Circle?
If you selected "Friend" above, please share the name of your friend.
Service Agreement*
Parent/Guardian Signature*
By typing your name you are electronically signing this intake form
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