Sunday Circle Sign-up - FCPalisades.com

Child's Name:*

First Name Last Name

Parent's E-mail:*

Sundays Attending:*

Have you registered for Sunday Circle in the past?

No, I have not yet filled out the necessary formsYes, I have already filled out all the necessary forms

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

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? (If yes, please specify.)*

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 Sunday Circle:

I Agree

I permit my child to be taken off Friendship Circle premises for local outings. (i.e. Fire Station 23)*

I agree

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:*

YesNo

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

$100/day

Please note: Private paid clients will not be denied participation due to financial constraints.

How will you pay?

Private PaidSelf-Determination Program

Private Paid:

Credit Card (3% CC Fee Applies)Check/CashI would like to discuss financial assitance.

Sunday Circle is Self-Determination-Friendly and promotes community integration (Code 331). Please work with your FMS provider to cover the cost of this program. For any further questions, please feel free to reach out to us at [email protected].

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

Child's Information:

Additional Contacts (In Case of Emergency):

Medical Information:

Parental Consent:

Sunday Circle Rates: