THE FRIENDSHIP CIRCLE - YOUR INFORMATION

“Friends Helping Friends ”

54 South Street

Westborough , MA 01581

(508)366-0499

www.fc.chabadwestboro.org

Child Application

Child Information

Parents Contact Information

Mother’s Name:*

Father's Name:

Mother’s Cell Phone:*

Father’s Cell:

Mother’s E-mail:*

Father’s E-mail:

Parent’s Occupation(s)(Optional) :

Give a brief description of your child :

Describe your child’s communication skills:

List your child’s favorite activities :

List your child’s least favorite activities:

What would you like your child to gain through The Friendship Circle program?

Names and Birth Dates of Siblings :

Other things you would like to tell us about your child :

Emergency Contact (other than parent)

Name:*

Phone:*

Please list any allergies:

Please list any medical conditions that we should be aware of :

Friends @ Home Program

When would you like the volunteers to come and visit your home?

(1st Choice) Day:		Time:
(2nd Choice) Day:		Time:

Parental Consent
	It is our pleasure to provide you with our Friends at Home service, however it is necessary for parents/guardian to assume responsibility to oversee activities shared together. I agree that a parent or legal guardian will be home at all times while volunteers are interacting with my child. I agree that my child’s photos may be used for any and all Friendship Circle publicity purposes. I agree to release the Friendship Circle, its providers and administrators, from all liability for any incident which affects the health, welfare, or safety of our child during their participation in the Friendship Circle Program.