FAMILY INTAKE FORM

To be completed by the parent or guardian of a child with Special Needs.

CHILD INFORMATION
Last Name   Address
First Name   City/State
Hebrew Name   Zip
Birthday     Home Phone
Age   Cell Phone
Grade   Email
School Name   Screenname
School Phone   Gender Male Female
         
FAMILY INFORMATION
MOTHER     FATHER  
Last Name   Last Name
First Name   First Name
Hebrew Name   Hebrew Name
Title   Title
Occupation   Occupation
Home Phone   Home Phone
Work Phone   Work Phone
Cell Phone   Cell Phone
E-mail Address   E-mail Address
         
MEDICAL INFORMATION
Medical Conerns / Diagnosis
  Medications Taken Reguarly
Any activities your child should not participate in?
Date of last tetnus shot (if known):
Medical / Environmental / Pet Allergies:
Dietary Restrictions: Vegetarian Lactose Intolerant Other/Food Allergies
         
GENERAL
Further Explantion of Medical Concerns / Diagnosis (if necessary)
Is your child completely toilet trained? YES NO
Please list any therapies your child is currently receiving, where the therapy is taking place, phone number & contact person
Are there any pets in your home? If so, please specify:
Names and ages of siblings residing in home with child
Please list your child's favorite activities
Give a brief description of your child
 Please list your child's least favorite activities
Describe your childs communication skills
  Please list your child's hobbies
What would you most like your child to gain by participating in Friendship Circle?
Other Comments, if any: 

         
PARENT MEDICAL RELEASE
My son/daughter has my permission to participate in Friendship Circle. I agree not to hold Friendship Circle liable for any accident, loss or theft that may occur during the course of an event. I have indicated any pertinent medical information above. I agree to the terms and conditions of this application.
I hereby give my child permission to participate in all activities planned by Friendship Circle.
Parent "Signature"   Date
         
FRIENDS AT HOME
How did you hear about our program?    
Times weekly you'd like to receive Friends at Home?  

Dates & Times of convenience for friends to visit:		  
First Choice   Time  
Second Choice   Time  
Third Choice   Time  
         
PARENTAL LIABILTY RELEASE
I, , agree that a paren/guardian will be home while voluntees are interacting wtih my child. I release the Friendship Circle, its providesr and administrators, from all liability for any incident whch affects teh health, welfare, or safety of my child, , in the provision of such service.
Please initial here:   Date
         
MISCELLANEOUS PARENTAL RELEASE
Please initial the following if applicable:  
I hereby give permission for my child's photo be put on the Friendship Circle Website
I hereby give permission for my child's photo to be used for publicity purposes (i.e. brochures, newspaper)