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The Friendship Café Winter Camp!
Join our Friendship Café Life Skills & Job Training Program for an incredible Winter Camp Program! Created with the goal to provide our adults with special needs an immersive, real- world environment where they can practice critical life and job skills, our program includes hands-on training in The Friendship Café, interpersonal & communication skills, a Mentorship Program, visiting local businesses and more! Get ready to add loads of fun to this really beneficial program with Art, Music, Yoga, Cooking & Baking, Zumba, Experiments, Pilates and In-house entertainment!
January 2 – 6 Monday – Friday 9:00 – 3:00 Age Group +18
Adult Participant Information:
Name
*
First
Last
Gender
*
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Female
Birthdate
*
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Address
Address Line 1
Address Line 2
City
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
*
Cell Phone
School
*
Religion
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 your child live with you?
*
Yes
No
Where does your child live?
*
Caregiver's Name
Caregiver's Phone Number
Medical Information
What are your young adult'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
*
Cell Phone:
*
Doctor's Name
*
Doctor's Phone Number
*
Health Insurance Provider:
Policy Number:
*
Permissions
I give The Friendship Circle of Greater Fort Lauderdale & The Friendship Café Life Skills & Job Training Program permission to contact my child'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 my child 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 my child. 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 the participant's photos to be used by The Friendship Circle of Greater Fort Lauderdale and Friendship Cafe Life Skills & Job Training Program for publicity purposes.
*
Yes
No
I hereby give permission for the participant to attend all field trips sponsored by The Friendship Circle of Greater Fort Lauderdale and Friendship Café Lifeskills & Job Training Program
*
Yes
No
Signature
*
Today's Date
*
Additional Information
Which languages does your child 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 your child 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.)
*
Tuition Information:
Winter Program Fee $450
Apply for Financial Aid/Scholarship* Apply
HERE
Total
$ 0.00
*At the Friendship Circle we believe that every adult with special needs deserves the chance at friendship & fun social interaction with peers their own age as well as the ability to gain crucial life & job skills! Please list in the comment box below how much you can pay and why you’re seeking financial aid at this time. We will be in touch regarding further documentation needed & do our very best to make it work!
Comments
Credit Card Information
Card Number
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Security Code
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