Family Sign Up Form - FCPalisades.com

Child Info

First Name*

First Name Last Name

Hebrew Name*

Gender*

MaleFemale

Child date of birth*

Month Day Year

Address*

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

Home Phone Number*

Area Code Phone Number

Child Phone Number If Applicable

Area Code Phone Number

Child E-mail If Applicable

School Attending*

Grade*

Please list siblings and their ages

Parents Info

Father Name*

First Name Last Name

Father Cell Number*

Area Code Phone Number

Father E-mail*

Is Father Jewish?*

Yes, by birthYes, by choiceNo

Mother Name*

First Name Last Name

Mother Cell Number*

Area Code Phone Number

Mother E-mail*

I would like to receive news and updates by email

Is Mother Jewish?*

Yes, by birthYes, by choiceNo

Parents' Marital Status*

MarriedDivorcedSingleWidowed

Tell us about your child

What does your child enjoy doing most? (Outdoor/indoor activities)*

Is there anything else you would like us to know about your child?*

Does your child have a medical diagnosis?

What are you looking for in a volunteer for your child?*

What do you hope to gain from the Friendship Circle?*

How did you find out about our program?*

Friends at Home Day Preferences

Day of week:* Check all that apply

Time of day:*

Notes:

I confirm that a parent/guardian will be home while volunteers are interacting with my child*

Yes

Parental Consent

I 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.*

Yes

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

YesNo

Today's date*

Month Day Year

Parent's Signature*