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Upcoming Events
Upcoming Events
Title
Start Date
End Date
Register Now
Birthday Circe @ Mesa Vista Farm
November 18, 2018 1:00 pm
November 18, 2018 3:00 pm
Register Now
1
Start
2
Emergency Contact Information
3
Tell us about your Child
4
Tell us about your Child
5
Tell us about your Child
6
Complete
Parent 1
Name Prefix
*
- Select -
Mrs.
Ms.
Mr.
Dr.
Rabbi
The Honorable
First Name
*
Middle Name
Last Name
*
Street Address
*
City
*
Postal Code
*
State/Province
*
Home Phone Number
*
Cell Phone Number
Email
*
Preferred Communication Method(s)
Home Phone
Postal Mail
Cell Phone
Fax
Facebook
Email
Text
Occupation
Marital Status
Single
Married
Separated
Divorced
Widowed
Family Religion
How did you hear about Friendship Circle?
Parent 2
Existing Contact
+ Create new +
Name Prefix
- None -
Mrs.
Ms.
Mr.
Dr.
Rabbi
The Honorable
First Name
Last Name
Share address of
Parent 1
Address
Street Address
City
Postal Code
State/Province
Phone Number
Email
Preferred Communication Method(s)
Home Phone
Postal Mail
Cell Phone
Fax
Facebook
Email
Text
Occupation
Relationship to Parent 1
Spouse of
Partner of
Emergency Contact
First Name
*
Last Name
*
Gender
- None -
Female
Male
Other
Phone Number
*
Email
*
Is this person allowed to pick up your child?
Yes
No
Child 1
Existing Contact
+ Create new +
How many children are you registering with Friendship Circle of Virginia today?
1
2
3
First Name
*
Last Name
*
Nickname
Share address of
- None -
Parent 1
Parent 2
Emergency Contact
Gender
*
- Select -
Female
Male
Transgender
Shirt Size
- None -
X-Small
Small
Medium
Large
X-Large
Birth Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
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2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
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?
Medical Information:
Please list any medical conditions we should be aware of.
Medications Taken Regularly
Name any Allergies (Food, Animals, Environment)
Dietary Restrictions
Lactose Intolerant
Vegetarian
Gluten Free
Kosher
Other Dietary Restrictions. Please explain.
Date of last tetanus shot (if known)
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
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29
30
31
Year
Year
1968
1969
1970
1971
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1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
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1991
1992
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2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
Medical Insurance Carrier
Policy Number
Doctor's Name
Doctor's Office Number
Hospital Affiliation
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.
I permit my child's photo to be used for publicity purposes. Names will not be used without prior consent.
Yes
No
I give my child permission to participate in all activities planned by Friendship Circle (unless stated above).
Yes
No
I give permission to administer the medications to my child, upon my request as per written instructions (non-emergency).
Yes
No
Who is filling out this form?
Mother
Father
Legal Guardian
Please type your signature:
Date:
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
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7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
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2019
2020
2021
2022
2023
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2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
Please enter your email address:
Please upload a current picture of your child.
Upload
Child 2 (if applicable)
Existing Contact
+ Create new +
First Name
*
Last Name
*
Nickname
Birth Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Gender
- None -
Female
Male
Transgender
Shirt Size
- None -
X-Small
Small
Medium
Large
X-Large
School your child attends?
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?
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?
Does your child need supervision and support during bathroom routines? If yes, please explain.
Is there anything else you would like to share with us about your child?
Medical Information:
Please list any medical conditions we should be aware of.
Medications Taken Regularly
Name any Allergies (Food, Animals, Environment)
Date of last tetanus shot (if known)
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
Dietary Restrictions
Lactose Intolerant
Vegetarian
Gluten Free
Kosher
Other Dietary Restrictions. Please explain.
Medical Insurance Carrier
Policy Number
Doctor's Name
Doctor's Office Number
Hospital Affiliation
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.
I permit my child's photo to be used for publicity purposes. Name will not but used without prior consent.
Yes
No
I give my child permission to participate in all activities planned by Friendship Circle (unless stated above).
Yes
No
I give permission to administer the medications to my child, upon my request as per written instructions (non-emergency).
Yes
No
Who is filling out this form?
Mother
Father
Legal Guardian
Please type your signature:
Date:
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
Please enter your email address:
Please upload a current picture of your child.
Upload
Child 3 (if applicable)
Existing Contact
+ Create new +
First Name
Last Name
Nickname
Gender
- None -
Female
Male
Transgender
Birth Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Shirt Size
- None -
X-Small
Small
Medium
Large
X-Large
School your child attends?
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?
Medical Information:
Medications Taken Regularly
Please list any medical conditions or diagnosis we should be aware of.
Name any Allergies (Food, Animals, Environment)
Date of last tetanus shot (if known)
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
Dietary Restrictions
Lactose Intolerant
Vegetarian
Gluten Free
Kosher
Other Dietary Restrictions. Please explain.
Medical Insurance Carrier
Policy Number
Doctor's Name
Doctor's Office Number
Hospital Affiliation
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.
I permit my child's photo to be used for publicity purposes. Name will not but used without prior consent.
Yes
No
I give my child permission to participate in all activities planned by Friendship Circle (unless stated above).
Yes
No
I give permission to administer the medications to my child, upon my request as per written instructions (non-emergency).
Yes
No
Please upload a current picture of your child.
Upload
Who is filling out this form?
Mother
Father
Legal Guardian
Please type your signature:
Date:
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
Please enter your email address:
Friends@Home Guidelines
It is very important for the safety of everyone that the following guidelines be read and agreed to prior to a Friends@home visit.
If their are weapons in the home. This includes any type of fire arm. I agree to keep them securely locked up during the Friends@home visit.
Yes
No
All prescription medication must be out of sight or locked up during a Friends@home visit.
Yes
No
I agree to have a background check on all individuals over 18 years who will be in the home during a Friends@home visit. FCVA will send you a link to complete the background check.
Yes
No
Thank you for becoming a Member of Friendship Circle of Virginia (FCVA). We will be in touch with you soon!
Please review the calendar section of our website for upcoming events!
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