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Participant Information
Name
*
First
Last
Gender
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Female
Birthdate
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Address
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Texas
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Vermont
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Washington
West Virginia
Wisconsin
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State
Zip Code
Home Phone
*
School
Grade
Religion
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How did you hear about The Friendship Circle?
*
Parent Information
Mother's Name (First Name, Last Name)
*
Mother's Cell
*
Occupation
*
Mother's Email
*
Father's Name (First Name, Last Name)
*
Father's Cell
*
Occupation
*
Father's Email
*
Marital Status
*
Married
Divorced
Does the participant live with you?
*
Yes
No
Where does the participant live?
Caregiver's Name
Caregiver's Phone Number
Medical Information
What are the participant's special needs?
*
Please list any allergies or medical conditions we should be aware of:
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Emergency Contact Name (First Name, Last Name)
*
Relationship to participant:
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Emergency Contact Phone Number
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Cell Phone:
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Doctor's Name
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Doctor's Phone Number
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Health Insurance Provider:
Policy Number:
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Permissions
I give The Friendship Circle of Greater Fort Lauderdale & The Friendship Café Life Skills & Job Training Program permission to contact the participant's doctor if emergency medical advice is needed and I can't be reached.
*
Yes
No
In case of a medical emergency requiring immediate emergency care, I authorize the paramedics to take the participant to the nearest hospital if necessary.
*
Yes
No
I authorize any adult acting on behalf of The Friendship Circle of Greater Fort Lauderdale or the Friendship Café Life Skills & Job Training Program to hospitalize or secure treatment for the participant. I further agree to pay for all charges for that care and/or treatment. It is understood that, if time and circumstances reasonably permit, The Friendship Circle will try to communicate with me prior to such treatment.
*
Yes
No
I permit my child/Young Adult's photos to be used by The Friendship Circle of Greater Fort Lauderdale for publicity purposes.
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Yes
No
I hereby give permission for my child/young adult to attend all field trips sponsored by the The Friendship Circle of Greater Fort Lauderdale & The Friendship Café Life Skills and Job Training Program
*
Yes
No
Signature
*
Today's Date
*
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
Other
What is the best method of handling 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 do they best communicate?
*
Verbal
Non-verbal
Sign
Other
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.)
Friendship Circle Programs
TEEN SCENE
>Sunday, twice a month, 3:00-4:30 PM Teen volunteers and teens with special needs get together monthly for social activities and group “hang outs”, where they can have a great time while enhancing their social skills!
YOUNG ADULT CIRCLE
>Thursday, twice a month, 6:00-7:30 PM Young adult volunteers and young adults with special needs come together monthly to form a social group in a non-judgmental and accepting environment. They get to experience an exciting array of activities such as karaoke, art, baking, sports and so much more.
CULINARY CLUB
>One Sunday a month, 4:00-5:00 PM Travel the world & discover different yummy cuisines with fun, talented chefs!! Socialize with friends, discover your hidden talents, and come home with deliciousness and lots of pride!!
FRIENDS AT HOME
>Once a week throughout the school year, accommodates a wide variety of schedules (Open for families who are a part of our Teen Scene Program) 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 while their teen volunteers learn the priceless value of giving.
MOM’S NIGHT OUT
A special evening, giving our dedicated & noble moms a chance to unwind & relax.
Life Skills and Job Training Program
Monday- Friday, 9:00 A.M- 3:00 P.M. Our goal is to provide our Adults with special needs with an immersive, real- world environment where they can practice critical life and job skills. The program includes hands on training in The Friendship Cafe, interpersonal & communication skills, academics such as basic math & reading, Yoga & relaxation techniques, a Mentorship program, Arts & more.
For Friends at Home Program – Please indicate your choice of days that work for a visit:
For Friends at Home Program – Choice of times:
The cost of the program is to allow us to continue servicing you to the highest standards possible. We want to ensure that we provide your child with a social, fun, hands on experience in a safe environment. No child will be turned away due to lack of funds!
Program Fee
Young Adult Circle – Program Fee $220 for the year
Teen Scene – Program Fee $220 for the year
Culinary Club – Program Fee $180 for the year
Friendship Café Life Skills and Job Training Program
Apply HERE
Friends at Home
Mom’s Night Out
No child will be turned away due to lack of funds! We can't afford to pay the program fee:
We can’t afford to pay the Young Adult program fee: Apply for scholarship
HERE
We can’t afford to pay the Teen Scene program fee: Apply for scholarship
HERE
We can’t afford to pay the Culinary Club program fee: Apply for scholarship
HERE
Please ensure to submit this form before applying for a scholarship.
I'd love to contribute with:
List any talents/methods you can help.
Total
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