Child Friendship House Registration After submitting your registration, you will receive a confirmation email with a welcome pamphlet. Included in the email will also be a few waivers and forms. Please read and sign, and send back our way to complete your registration. Thank you! Please enable JavaScript in your browser to complete this form.1General Information2Medical Information3Program RegistrationChild's Name *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What school does your child attend? *If your child doesn't attend any school, please explain?Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMother's Name *FirstLastMother's Cell Phone Number *Mother's Email *Father's Name *FirstLastFather's Cell Phone Number *Father's Email *Marital Status? *MarriedDivorcedWith whom does your child live with? *What is your religion? *Which Temple are you affiliated with? *Comment or MessageNextWhat are your child's special needs? *Please list any allergies or medical conditions we should be aware of: *Emergency Contact Name *FirstLastRelation to Child? *Phone Number *Cell Phone *Consent: *I give Friendship House of Boca Raton permission to contact my child's doctor if emergency medical advice is needed and I can't be reachedDoctor's Name *FirstLastDoctor's Phone Number *Consent: *In case of a medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary.Health Insurance Provider: *Policy Number: *Additional Information:What languages does your child speak? *Which activities does your child enjoy doing most? *Which activities does your child not like doing? *Are there any activity restrictions for your child? *Does your child occasionally exhibit any of the following behaviors?BitingGrabbingKicking CursingHitting Pulling HairOtherPlease Explain *What is the best method of handling the situation?Is your child completely toilet trained? *YesNoIs your child sensitive to any of the following? *LightNoiseTouchMovementN/AHow does your child best communicate? *VerbalNon-VerbalSignOtherPlease Explain *Please list any therapists that your child is currently seeing: *Is there anything else we should know about your child? (attention span, outgoing/shy, etc.)NextFriends@Home. Ages 4-17Once a week throughout the school year, Friends@Home accommodates a wide variety of schedules. Friends@Home pairs teenage volunteers and children with special needs for hours of fun and friendship through weekly home visits. This provides children the chance to bond with their volunteers in an environment they are most comfortable in, while their parents and siblings receive much-needed respite. Through the weekly visits, the pair establish a warm friendship that combats the loneliness and isolation so often felt by individuals with special needs. At the same time, their teen volunteers learn the priceless value of giving.I would like my child to be a part of Friends@Home. *YesNoBackground CheckOur insurance requires that anyone who interacts with minors needs to be screened. That said, both parents and adults in the house, while a Friendship House visit is taking place, need to complete a background check. We have partnered with Sterling Volunteers to complete this process securely. The Friendship House will never see your personal information or background information and will only receive a report verifying your ability to care for minors. By going to www.SterlingVolunteers.com, you can securely enter your information. By providing this information electronically, we can both ensure that your information is secure and speed up the process considerably. If you sign up for our Friends@Home program, In your welcome email, you will be provided with our unique Friendship House code to use when entering your information.Please provide your first choice of time for the Friends@Home visit. *DaySundayMondayTuesdayWednesdayThursdayFridayShabbat *Select the beginning of the hour. Friends@Home is a one-hour program.Please provide your second choice of time for the Friends@Home visit. *DaySundayMondayTuesdayWednesdayThursdayFridayShabbatSelect the beginning of the hour. Friends@Home is a one-hour program.Sunday Circle. Year 2020-21, Ages 4 +Sunday Circle offers a wonderful opportunity for children to gain from group activities while still receiving one-on-one attention from their volunteers. Activities include sports instruction, music and movement instruction, arts and crafts. Sunday Circle is a two-hour drop off program, creating an excellent respite opportunity for parents. Sunday Circle occurs up to twice a month from 2:00 - 4:00 pm. Dates for 2020-21 December 6 Session 1. January 10 Session 2. January 24 Session 3. February 7 Session 4. March 7 Session 5. April 11 Session 6. April 25 Session 7. May 9 Session 8. May 23 Session 9.I would like my child to be a part of Sunday Circle. *YesNoI’d love to contribute with: (List any talents/ methods you can help)BackPhoneSubmit