Life Skills Program Registration

PARTICIPANT INFORMATION:

Name: *

First

Last

Name child prefers to be called:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate *

Home Phone *

Cell Phone *

Gender *

Male
Female

Religion

Primary Language Spoken *

Please upload a current photo of participant *

Click or drag a file to this area to upload.

Current School/Program Information

Current school or Program the participant attends (N/A if not applicable) *

Previous school or program *

Current Grade (N/A if not applicable) *

Does this participant have an IEP/PSSP or 504 plan? *

No
Yes (If yes, please upload documents here)

Students reading level (1st-12th grade) *

Students writing level (1st-12th grade) *

Does this participant currently attend any other social programs (yes/no) *

GUARDIAN INFORMATION

Primary Guardian *

First

Last

Relationship to participant *

Cell Number of Primary Guardian

Email of Primary Guardian *

Home Address of Primary Guardian

same as participant

Address

Address Line 1

Address Line 2

City

State

Zip Code

Occupation of Primary Guardian

Secondary Guardian *

First

Last

Relationship to participant *

Cell Number of Secondary Guardian

Email of Secondary Guardian *

Home Address of Secondary Guardian

same as participant

Address

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status of Guardians *

Married
Divorced
Not applicable

Does the participant live with a separate caregiver *

MEDICAL INFORMATION

Does the participant have any allergies or food sensitivities *

Does the participant take medication on a regular basis *

Does the participant have any activity restrictions? *

Which activities does the participants NOT like doing? *

Tell us more! Please share any additional information you would like the us to know about the participant

PRIMARY INSURANCE

Name of Primary Physician *

Phone Number of Primary Physician *

Participant's Insurance company *

Insurance member ID number *

THERAPY

If yes, please list the name of the company providing services and their contact number: *

Is the participant completely toilet trained? *

How does the participant best communicate? *

Verbal
Non-verbal
Sign
Other (please specify)

Kindly elaborate on the behavior/s you selected. Pls include triggers and best way to handle the situation. *

EMERGENCY CONTACT INFORMATION

In case of emergency if the Guardians listed above can not be reached please list two adults OTHER THAN the Guardians above who will take responsibility for your child.

Emergency Contact Name #1 *

First

Last

Relationship to participant: *

Cell Number of Emergency Contact #1

Emergency Contact Name #2 *

First

Last

Relationship to participant: *

Cell Number of Emergency Contact #2

PERMISSION AND WAIVERS

Photos *

I permit the participants' photos to be used for publicity purposes by the The Friendship Life Skills & Job Training Program and its partners as it relates to Friendship Circle.

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 will not 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 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.

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 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 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
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;
● 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;
● 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.;
● 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;
● 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;
● 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.

I/We understand that (my/our) participant is/are registered for the entire school year and that no reduction of the full year's tuition and fee obligation can be made for absence, voluntary or involuntary withdrawal, or expulsion.

I(We) give permission for my participant to go on any school trip during the 2023-2024 school year.

*If both parents are living, both must sign this contract. Otherwise, the participant's guardian and person having financial responsibility for this contract must sign. Your typed name below will represent your electronic signature. The Friendship Life Skills & Job Training Program accepts your (the Parent's) electronic signature in place of a handwritten signature on a hard copy page.

Name of Guardian 1 *

Signature of Guardian 1 *

Name of Guardian 2 *

Signature of Guardian 2 *

Today's Date *

Tuition and Registration:

Application will only be processed with a $180 registration fee. Tuition payments will only be accepted upon participants approval into the program.

$180 Registration Fee, $18,000 Tuition for Entire Year

If accepted, please charge me a one time fee of $18,000 for the year.
If accepted, please charge 10 monthly payments of $1,800 beginning August 1st.
Apply for scholarship. Download scholarship application here.

Total

$ 0.00

Credit Card Information *

Card Number

Expiration

Security Code

By clicking the submit button below, your credit card will be charged for the total amount reflected above.

PARTICIPANT INFORMATION:

Current School/Program Information

GUARDIAN INFORMATION

MEDICAL INFORMATION

PRIMARY INSURANCE

THERAPY

EMERGENCY CONTACT INFORMATION

PERMISSION AND WAIVERS

Tuition and Registration:

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