Share address of
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School your child attends?
Please list your childs siblings and their ages.
Tell us about your Child:
Disability (Please describe)
What is your child's primary mode of communication?
Are there any specific behaviors your child has that we should be make aware of?
Are there any aggressive behaviors that your child exhibits?
What makes your child happy or upset?
How does your child react when upset?
What are some of the best strategies to help calm your child?
What is your child sensitive to?
Does your child have any stimming behaviors; how should they be responded to?
Does your child need supervision and support during bathroom routines? If yes, please explain.
What are your child's favorite activities?
Are there any activities that your child should not be participating in due to a limitation or medical condition?
Is there anything else you would like to share with us about your child?
Please list any medical conditions we should be aware of.
Medications Taken Regularly
Name any Allergies (Food, Animals, Environment)
Other Dietary Restrictions. Please explain.
Medical Insurance Carrier
Medical and Emergency Release
My son/daughter has my permission to attend Friendship Circle events. I agree not to hold Friendship Circle liable for any accident, loss or theft that may occur during the course of an event. I hereby give my permission to the physician selected by The Friendship Circle to hospitalize, and/or secure necessary treatment or anesthesia for my child, as named above, in the event that I cannot be reached in an emergency. I hereby give my permission that paramedics can transport my child to the nearest hospital, if necessary. I have indicated any pertinent medical information above. I give permission for my child’s photo to be used for publicity purposes (i.e. brochures, newspapers, website, etc.) I agree to the terms and conditions of this application. Additionally, I am initialing below that I am agreeing to everything in this form by my signature below.
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