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(754) 800-1770
Office@friendshipfl.org
Sun - Fri: 9:00 - 5:00
Camera-retro
Facebook
Youtube
Donate
About
Home Education & Life Skills Program
About Our Program
Registration
Calendar
Classes
Tuition
Summer Registration
Home Education & Life Skills Program
Information Request
Social Programs
Social Program Calendar
Our Programs
Culinary Club
Teen Scene
Young Adult Circle
Music Circle
Mom’s Night Out
Participant Registration
Volunteers
Volunteers
Teen Leadership Board
Upcoming Events
Blog
Friendship Grill
Employment Opportunities
About
Home Education & Life Skills Program
About Our Program
Registration
Calendar
Classes
Tuition
Summer Registration
Home Education & Life Skills Program
Information Request
Social Programs
Social Program Calendar
Our Programs
Culinary Club
Teen Scene
Young Adult Circle
Music Circle
Mom’s Night Out
Participant Registration
Volunteers
Volunteers
Teen Leadership Board
Upcoming Events
Blog
Friendship Grill
Employment Opportunities
Donate
About
Home Education & Life Skills Program
About Our Program
Registration
Calendar
Classes
Tuition
Summer Registration
Home Education & Life Skills Program
Information Request
Social Programs
Social Program Calendar
Our Programs
Culinary Club
Teen Scene
Young Adult Circle
Music Circle
Mom’s Night Out
Participant Registration
Volunteers
Volunteers
Teen Leadership Board
Upcoming Events
Blog
Friendship Grill
Employment Opportunities
About
Home Education & Life Skills Program
About Our Program
Registration
Calendar
Classes
Tuition
Summer Registration
Home Education & Life Skills Program
Information Request
Social Programs
Social Program Calendar
Our Programs
Culinary Club
Teen Scene
Young Adult Circle
Music Circle
Mom’s Night Out
Participant Registration
Volunteers
Volunteers
Teen Leadership Board
Upcoming Events
Blog
Friendship Grill
Employment Opportunities
Donate
The Friendship Circle
The Friendship Music Circle
Every Fridays, 11:00 - 12:00 pm
*caregiver/guardian is required to remain on the premises during the program.
REGISTER BELOW
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Participant Information
Name
*
First
Last
Gender
*
Male
Female
Birthdate
*
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YYYY
2027
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1920
Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
*
To see our privacy statement,
click here.
School
Grade
Religion
*
How did you hear about The Friendship Circle?
*
Parent Information
Mother's Name (First Name, Last Name)
*
Mother's Cell
*
To see our privacy statement,
click here.
Occupation
*
Mother's Email
*
Father's Name (First Name, Last Name)
*
Father's Cell
*
To see our privacy statement,
click here.
Occupation
*
Father's Email
*
Marital Status
*
Single
Married
Divorced
Does the participant live with you?
*
Yes
No
Where does the participant live?
Caregiver's Name
Caregiver's Phone Number
To see our privacy statement,
click here.
Medical Information
What are the participant's special needs?
*
Please list any allergies or medical conditions we should be aware of:
*
Emergency Contact Name (First Name, Last Name)
*
Relationship to participant:
*
Emergency Contact Phone Number
*
To see our privacy statement,
click here.
Cell Phone:
*
To see our privacy statement,
click here.
Doctor's Name
*
Doctor's Phone Number
*
To see our privacy statement,
click here.
Health Insurance Provider:
Policy Number:
*
Additional Information
Which languages does the participant speak?
*
Which activities do they NOT like doing?
*
Do they have any activity restrictions?
*
Does he/she travel alone or with equipment?
*
Does he/she occasionally exhibit any of the following behaviors?
*
Biting
Grabbing
Kicking
Cursing
Hitting
Pulling Hair
None
Other
Kindly elaborate on the behavior/s you selected. Pls include triggers and best way to handle the situation.
*
Is the participant completely toilet trained?
*
Yes
No
Is he/she sensitive to any of the following?
*
Light
Noise
Touch
Movement
N/A
How does the participant best communicate?
*
Verbal
Non-verbal
Sign
Other (pls specify below)
Other specification
*
Please list any therapists that he/she is currently seeing:
Is there anything else we should know about them? (attention span, outgoing/shy, strengths/weaknesses etc.)
Permission and Waivers
Photos
*
I grant The Friendship Circle and its partners permission to use the participant's name, image, likeness, or recording for publicity purposes.
Medical
*
I do hereby agree not to hold The Friendship Circle nor Las Olas Chabad Jewish Center, Inc. liable for any injury, loss, or theft that may occur during the participant’s involvement at a Friendship Circle event. I hereby give my permission to the Friendship Circle to secure necessary treatment including but not limited to anesthesia and hospitalization in the event of any such injury to the participant, should a staff member of the Friendship Circle or Las Olas Chabad Jewish Center, Inc. deem it necessary. I hereby give my permission to such person to engage on my behalf and on behalf of the participant, to transport the participant to a hospital if necessary. I have indicated to Friendship Circle all pertinent medical information regarding the participant.
Liability
*
I do hereby agree not to hold The Friendship Circle nor Las Olas Chabad Jewish Center, Inc. or their agents, volunteers, and other participants liable for any injuries or damages which may occur in any Friendship Circle event and to and from such events. I hereby waive all rights to sue The Friendship Circle and/ or Las Olas Chabad Jewish Center, Inc. for any such incidents which may occur including but not limited to the transit to and from The Friendship Circle events.
Code of Conduct
*
I have carefully read and agree to abide and be bound by all additional rules and policies in the Friendship Circle Code of Conduct and any additional rules pertinent to specific events. THE FAILURE TO ABIDE BY THE CODE OF CONDUCT & ANY SUCH RULES MAY, IN THE EXERCISE OF FRIENDSHIP CIRCLE’S SOLE AND ABSOLUTE DISCRETION, RESULT IN THE TERMINATION OF ALL FURTHER PROGRAM ACTIVITIES.
Friendship Circle of Greater Fort Lauderdale provides very special and unique opportunities for volunteers, special friends, and their families to enrich the lives of each other. In doing so, most participants will encounter new and sometimes challenging situations. Thus, it is imperative to set expectations at the beginning so that volunteers, special friends, and parents understand what they can expect. Therefore, volunteers, special friends, and their families each certify and agree by signing below that they:
As a Parent/Guardian of a special needs child of Friendship Circle or as a volunteer:
• I understand that Friendship Circle will match my child with a teenage/ young adult volunteer.
• I understand that it is necessary for me as parent(s)/guardian(s) to assume full oversight and supervision responsibilities with respect to all activities Friendship Circle’s assigned volunteer(s) share(s) with my child in connection with his/her participation in the program;
• I understand that as a volunteer, I agree to be bound by the Rules and Regulations and Standards of Conduct of the Friendship Circle and that I am a volunteer without payment or expectation of payment or reimbursement of expenses except when advised in writing prior to any such expenditure.
• I understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct;
• I understand that participation in Friendship Circle activities involves a certain degree of risk, both physically and emotionally demanding. I have considered the risk involved and have given consent as indicated below for my participation
• I will not use or possess any illegal drug, alcohol or controlled substances at any time, including at Friendship Circle events or programs;
• I will not bring any weapons, firearms or other dangerous items to any Friendship Circle event or program and I will not have any unsecured firearms in a home in which hosts a Friends at Home program;
I have not and do not have any individual that has been convicted of a crime, other than minor traffic violations, living at or visiting a home that hosts a Friends at Home program and have not themselves been convicted of a crime;
• Do not themselves have and do not have any individual that has a history of violence or abuse of any kind living at or visiting a home that hosts a Friends at Home program;
• I acknowledge the risk of injury from activities involved in Friendship Circle events and knowingly and freely assume all such risks. In the event I observe any particular hazard that I believe could cause injury to a participant, I will immediately inform Friendship Circle staff of such hazard.;
• I will not participate in any activity that you believe you and/or your child cannot perform in accordance with the Friendship Circles activities’ instructions or in a safe manner;
• I understand that as a volunteer, Friendship Circle expects me to behave responsibly. I agree to utilize my best judgment and sense of responsibility when spending time with the participant with whom I am matched;
• I understand that the use of a cell phone during a Friendship Circle event does not promote a healthy friendship and should only be used in case of emergency;
• I agree to respect the privacy of all participants of the Friendship Circle and to keep personal information confidential;
• I understand that once I commit to attend an event, the Friendship Circle staff and special friends expect me to be there. I agree to attend and give it my best effort;
• If someone gets hurt or some other incident occurs while I am volunteering, it is my responsibility to immediately report the occurrence to Friendship Circle staff;
• I understand the importance of open communication and will try my best to maintain it, by ensuring that In the case a Friendship Circle staff member contacts me, I will do all I can to return the contact in any form within 24 hours;
• I agree Friendship Circle is not responsible for any damage or injury to myself, my child/participant or my property in regard to my participation in any Friendship Circle activity;
• I acknowledge that Friendship Circle is an independently owned, operated and controlled local corporation.
I have carefully read and agree to abide and be bound by all additional rules and policies in the Friendship Circle Handbooks and any additional rules pertinent to specific events. THE FAILURE TO ABIDE MAY, IN THE EXERCISE OF FRIENDSHIP CIRCLE’S SOLE AND ABSOLUTE DISCRETION, RESULT IN THE TERMINATION OF ALL FURTHER PROGRAM-RELATED VISITATIONS WITH YOUR CHILD.
You may also access a copy of
Friendship Circle Code of Conduct
here.
Parent's or caregiver's presence
*
I understand that the participant's parent or caregiver must be present during each Music Circle session.
Signature 1
*
Clear Signature
Name of Parent 1 or Guardian
*
First
Last
Relationship to the Participant
*
Date Today
*
Signature 2
Clear Signature
Name of Parent 2
First
Last
Relationship to the Participant
Date Today
Please upload a latest photo of the participant
*
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