Your Child Child's 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 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 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 Phone Number* Area Code Phone Number Child's E-mail School* Grade* Parents Mother's Name First Name Last Name Father's Name First Name Last Name Mother's E-mail Father's E-mail Mother's Cell Number Area Code Phone Number Father's Cell Number Area Code Phone Number Friends @ Home If your child will be participating in F@H please fill this out. When would you like the volunteers to come and visit your home? (1st choice) Day of the week Time: (2nd choice) Day of the week Time: What does your child enjoy doing most? Is there anything in particular that your child does not like doing? Is there anything we need to know about your child? Parent's Signature* Date* Emergency Form Emergency contact (other then parent) Name Emergency Contact Phone Number Area Code Phone Number Emergency Contact Cell Number Area Code Phone Number Medical Information Please list any allergies Please list any medical conditions that we should be aware of If parents cannot be reached and emergency medical advice is needed, permission is given to the Friendship Circle staff to phone my Child’s doctor. Doctor: Doctor Phone Number Area Code Phone Number Doctor 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 Doctor’s hospital affiliation In case of medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital, if necessary. Health insurance: Name Heath Insurance Number Parent's Signature* Date* PARTICIPANT CODE OF CONDUCT As a participant in Friendship Circle: I understand that Friendship Circle will match me with a teenage volunteer. I understand that, it is necessary for me and my parent(s)/guardian(s) to assume full oversight and supervision responsibilities with respect to all activities Friendship Circle’s assigned teen mentor(s) share(s) with my child in connection with his/her participation in the program. I agree to respect the privacy of all participants of the Friendship Circle and to keep personal information confidential. If someone gets hurt or some other incident occurs during a Friendship Circle program, it is my responsibility to immediately report the occurrence to Friendship Circle staff. AS AN EXPRESS PRECONDITION OF YOUR CHILD’S ADMISSION INTO THE PROGRAM, THIS FORM MUST COMPLETED. EXECUTION OF THIS FORM SERVES AS YOUR ACKNOWLEDGEMENT: (1) OF THE CRITCIAL IMPORTANCE FRIENDSHIP CIRCLE PLACES ON YOUR AGREEMENT TO AT ALL TIMES HAVE AT LEAST ONE PARENT/GUARDIAN "ON PREMISES" DURING THE ENTIRETY OF EACH FRIENDS@HOME RELATED VISITATION; AND (2) THAT THE PARENT/GUARDIAN TAKES FULL RESPONSIBILITY FOR EVERYTHING THAT TRANSPIRES DURING THE VISIT AND EXEMPTS FRIENDSHIPCIRCLE FROM ANY RESPONSIBILITY OR LIABILITY; THE FAILURE TO ABIDE BY ANY OF THESE REQUIREMENTS MAY, IN THE EXERCISE OF FRIENDSHIP CIRCLE’SSOLE AND ABSOLUTE DISCRETION, RESULT IN THE TERMINATION OF ANY OR ALL FURTHER PROGRAM RELATED ACTIVITIES WITH YOUR CHILD. I have carefully read and agree to abide and be bound by all additional rules and policies in the Friendship Circle Handbook and any additional rules pertinent to specific events.I give my child permission to participate in Friendship Circle. I understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and give consent for myself and/or my child to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide and be bound by all applicable rules and policies as set forth in the Friendship Circle Handbook, as it may be modified from time to time and any additional rules pertinent to specific events. I understand that this local Friendship Circle is independently owned, operated and controlled I release the Friendship Circle and its employees, directors, officers, and volunteers as well as its affiliates and all other organizations associated with Friendship Circle from any and all claims or liability arising out of this participation. I grant Friendship Circle permission to use my and my child’s name, image, likeness, or recording in connection with any promotional materials including, but not limited to, brochures, advertising, and broadcasts. I agree to the terms above. Please initial:* Participant’s Name:* Participant’s Signature Parent/ Guardian’s Name* Parent/ Guardian’s Signature* Date* PARTICIPANT’S COMMITMENT TO EVERYONE’S SAFETY AND WELL-BEING Friendship Circle provides very special and unique opportunities for volunteers, special friends and their families to enrich the lives of each other. In doing so, most participants will encounter new and sometimes challenging situations. Thus, it is imperative to set expectations at the beginning so that volunteers, special friends, and parents understand what they can expect. Therefore, volunteers, special friends, and their respective families each certify and agree to the following by signing below that I: Understand that participation in this activity is entirely voluntary and requires everyone to abide by applicable rules and standards of conduct; Understand that photographs can be private and sensitive and should not be shared by all. Do not use or possess any illegal drug, alcohol or controlled substances at any time, including at Friendship Circle events or programs; Do not have any alcohol or tobacco products at Friendship Circle events or programs; Do not bring any weapons, firearms or other dangerous items to any Friendship Circle event or program; Do not have any unsecured firearms in a home which hosts a Friends at Home program; Have not and do not have any individual that has been convicted of a crime, other than minor traffic violations, living at or visiting a home that hosts a Friends at Home program and have not themselves been convicted of a crime; Do not have any individual that has a history of violence or abuse of any kind living at or visiting a home that hosts a Friends at Home program; Agree to have a background check performed on me; Understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for me and/or my child to participate in this activity and knowingly and freely assume all such risks; Will not participate in any activity that I believe I and/or my child cannot perform in accordance with the Friendship Circles activities’ instructions or in a safe manner; If I observe any significant hazard during my or my child’s participation in any event or program, I will stop and/or have my child stop participating in the event and inform the Friendship Circle of such hazard immediately; Agree to abide by and perform everything stated in the Handbook in its entirety. Agree Friendship Circle is not responsible for any damages to personal property or injury in which the Friendship Circle had no knowledge of the particular hazard, or any activity outside of Friendship Circle sponsored events; Acknowledge that Friendship Circle is an independently owned, operated and controlled local corporation. Release Friendship Circle, the directors, board, officers, activity coordinators, and all employees, volunteers, related parties, and other organizations associated with the activity from any and all claims or liability arising out of this participation; Agree that in case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities. Please sign as appropriate: Participant’s Name:* Participant’s Signature Date* Parent/ Guardian’s Name* Parent/ Guardian’s Signature* Date* Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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