Camper Sign Up

New to FC Palisades?

Please reach out to [email protected] to schedule an intake meeting and request a participant application in order to attend FC Extreme.

Child's Name:*

First Name Last Name

Date of Birth:*

Month Day Year

Parent's E-mail:*

Days Attending:*

August 4August 5August 6August 7

T-shirt Size: * For safety, a FC Extreme T-shirt must be worn daily

Shoe Size:* (For Bowling)

Is there any information we may need to make camp exciting, comfortable, and safe for your child?*

Are there any fears you'd like us to know about (animals, loud noises, etc) and suggestions of how we can deal with them?*

Is your child completely toilet trained?*

YesNo

Does your child need bathroom assistance?*

YesNo

Is there anything else we should know about your child?*

Does your child have a friend that would be interested in this program?

yesno

Emergency Contact #1:*

First Name Last Name

Relationship to Child:*

Phone Number:*

Emergency Contact #2:*

First Name Last Name

Relationship to Child:*

Phone Number:*

Health Insurance Provider:*

Policy Number:

Name of Doctor:*

Doctor's Phone Number:*

Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Doctor's Hospital Affiliation:*

Does your child have any allergies? (If yes, please specify.)*

Does your child take medication during the hours of camp? * FC Staff are not able to administer medication

YesNo

Additional Medical Information:

In the event that neither parent nor the emergency contact can be reached, Friendship Circle has my permission to render any necessary first aid or to secure care by a physician to my child while attending FC Extreme. I further agree to pay all charges for that care and/or treatment.*

I Agree

I permit my child to to attend and participate in all trips and outings organized by Friendship Circle as part of the program.*

I agree

I give permission to The Friendship Circle to transport my child to and from excursions while my child is in their care. I agree to release the Friendship Circle and its providers and administrators, from all liabilities for any incident which affects the health, welfare and safety of my child during the provided transportation.*

I agreeI will arrange transportation to and from trips for my child.

In the event that my child is unable to attend one of the below sessions, I will notify The Friendship Circle as soon as possible so they can plan accordingly.*

I agree

I permit my child's photo to be used for publicity purposes:*

YesYes, but only for Friendship Circle social media and literatureNo

What would you prefer when group photos are taken?*

My child can be in group photos as long as their face is not highlightedPlease ask my child to step out of group photos.

I have carefully considered the risks involved and agree to allow my child(ren) to participate in the activities with The Friendship Circle. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct as set forth by Friendship Circle. I understand that Friendship Circle is independently owned and operated. In consideration of the opportunity to send my child to The Friendship Circle, and by engaging in participation, I, myself, and on behalf of my child, hereby agree to release, hold harmless, and waive any and all claims against The Friendship Circle and its employees, directors, officers, and volunteers, as well as its affiliates and all other organizations associated with The Friendship Circle, from any and all claims or liability arising out of this participation. I understand that this form involves the release of legal rights.

By entering my initials below, I agree to each statement above and release The Friendship Circle of the West Coast from any and all liability.

Parent Signature:*

Date:*

Month Day Year

at Hour Minutes

$175/day

Please note: No member will not be denied participation due to lack of funds.

If you would like to pay through Regional Center or Self-Determination Program, please contact Rabbi Shimon at [email protected]

Payment Method:*

Credit Card (3% processing fee applies)I will contact Rabbi Shimon to discuss a payment plan.

Payment:*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Total:

$0.00

Looking forward to an awesome camp experience together!

FC Extreme Summer 2025: Camper Application

Additional Contacts (In Case of Emergency):

Medical Information:

Parental Consent:

FC Extreme Summer 2025 Rates: