FCLA Child Application 2021-2022

Is your child a:

New Participant Returning Participant
Please note that this form is only in addition to an intake meeting. We require a parent to attend an intake meeting before their child attends any programs.

To schedule an intake meeting, email Miriam at: miriam@fcla.org.
New Child Information
Full Name *

First Name Last Name
Hebrew Name
Your Jewish Name
Gender *

Male Female
Date of Birth *

Month Day Year
Date
School Attending *
Grade *
Returning Participant Update Form

Need to update other information? Please enter below:
Is there anything NEW we need to know about your child? *
Are there any new behaviors we need to know about?

Yes No
Please Describe:
Child Email (if applicable)
example@example.com
Home Phone *

Area Code Phone Number
Home Phone (if needs to be updated)

Area Code Phone Number
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Have you moved within the past year?

Yes No
New Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Parent/Guardian Status *
Child Lives With *
Does your child exhibit any of the following behaviors? *

Biting Cursing Grabbing Hitting Kicking Pulling Hair None
What activities does your child enjoy? *
To what personality does your child respond to best? (Volunteers will be assisting your child) *
Is there anything else need we to know about your child? *
How were you referred to us?
Parents/Guardian Information
Mother's Name *

First Name Last Name
Mother's Hebrew Name
Mother's Mobile Phone *

Area Code Phone Number
Mother's Mobile Phone (if needs to be updated)

Area Code Phone Number
Mother's Occupation *
Mother's Place of Employment
Mother's Work Address

Street Address

Street Address Line 2

City State

Zip Code
Mother's Work Phone *

Area Code Phone Number
Mother's Work Phone (if needs to be updated)

Area Code Phone Number
Mother's Email *
example@example.com
Mother's Email (if needs to be updated)
example@example.com
Synagogue Affiliation
Father's Name *

First Name Last Name
Father's Hebrew Name
Home Address (if different than child's)

Street Address

Street Address Line 2

City State

Zip Code
Home Phone (if different than child's)

Area Code Phone Number
Father's Mobile Phone *

Area Code Phone Number
Father's Mobile Phone (if needs to be updated)

Area Code Phone Number
Father's Occupation *
Father's Place of Employment
Father's Work Address

Street Address

Street Address Line 2

City State

Zip Code
Father's Work Phone *

Area Code Phone Number
Father's Work Phone (if needs to be updated)

Area Code Phone Number
Father's Email *
example@example.com
Father's Email (if needs to be updated)
example@example.com
Synagogue Affiliation
Medical Information
Child's Legal Name *

First Name Last Name
Any presenting medical conditions or allergies? If yes, please list medications and frequency. *
If not applicable, please enter "None"
If yes, please specify any special reminders or assistance your child needs
Is your child on a restrictive diet? *

Yes No
If YES, please provide details:
Is your child toilet trained? *

Yes No
18 or over?
Doctor *

First Name Last Name
Doctor's Phone Number *

Area Code Phone Number
Insurance Information
Insurance Carrier *
Policy Number *
Insurance Phone Number *

Area Code Phone Number
Have there any changes in your child's medical condition/information within the past year?

Yes No
Please Provide Details:
Are there any changes in your child's insurance information within the past year?

Yes No
Please Provide Details:
Do you have new emergency contacts?

Yes No
Please Provide Details:
If your child has any NEW allergies and/or dietary restrictions, please list them:
Emergency Contact Information
Emergency Contact #1 Name *

First Name Last Name
Emergency Contact #1 Mobile Phone *

Area Code Phone Number
Emergency Contact #1 Relationship to Child *
Emergency Contact #2 Name *

First Name Last Name
Emergency Contact #2 Mobile Phone *

Area Code Phone Number
Emergency Contact #2 Relationship to Child *
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Covid-19 Waiver to Participate

WAIVER, RELEASE, AND HOLD HARMLESS

Friendship Circle of Los Angeles (“FCLA”) cares deeply about the health and well being of all participants. In consideration of being allowed to participate in any and all FCLA programs, related events, and activities and the use of FCLA facilities or enter and access FCLA (“the Programs”) I, the undersigned participant and/or on behalf of the participant acknowledge, understand, and agree that:

I am fully aware there are several risks associated with me participating in the Programs or entering, accessing, or otherwise using FCLA during a time of pandemic due to the novel coronavirus (“COVID-19”) that has been confirmed throughout the world, including COVID-19 cases in areas in which the Programs at FCLA may be located.

I understand that my potential exposure to COVID-19 through my participation in the programs, use of FCLA, or contact with other participants in the Programs or at FCLA. I also acknowledge that FCLA is not responsible for my safety against COVID-19 and makes no warranties, guarantees, or representations about the safety or condition of its facilities, employees, other participants, or third parties at FCLA.

I further acknowledge that, due to the nature of the activities associated with the Programs, social distancing of six or more feet between persons is not always possible and I may be placed in proximity to or come in contact with individuals, equipment, and/or surfaces that have been contaminated with or may transmit COVID-19 or other diseases. I fully understand and appreciate the known and potential dangers of participating in the Programs, including exposure to COVID-19, which could result in further transmission to others, quarantine, isolation, serious illness, disability, and/or death. I hereby agree my involvement and participation in the Programs is voluntary, and I knowingly, freely, unconditionally, and expressly assume any and all risks associated with the Programs and FCLA, including risks not known or reasonably foreseeable to me at this time.

I further acknowledge that wearing a mask or a face shield may be difficult for individuals with special needs and that there may be times when certain participants will remove the face coverings. This will actually serve as an opportunity for FCLA staff to teach life skills and the importance of wearing a face covering.

During my participation in the Programs, I agree I will conduct myself in a safe and reasonable manner, including by complying with all health and safety protocols and instructions provided to me in connection with the Programs and reporting and disclosing to FCLA any COVID-19 related symptoms (i.e. fever, cough, shortness of breath, chills, repeated shaking with chills, muscle pain, headache, sore throat and loss of sense of taste or smell) I may experience. I agree, represent, and warrant I will not enter, access, or otherwise use the FCLA facility if I experience COVID-19 related symptoms or test positive for or am otherwise diagnosed with COVID-19 or am exposed to anyone with COVID-19.

I, on behalf of myself, my heirs, executors, and any member of my family, hereby release, discharge, and hold harmless the Friendship Circle of Los Angeles and each of their officers, executives, officials, agents, employees, instructors, contractors, representatives and partners, as well as other participants, sponsors, advertisers, owners, and lessors of premises used for the Programs and related activities, from any and all claims, causes of action, demands or liability in any way relating to, or arising from the Programs and/or my use of the FCLA facility, including, without limitation, any personal or other injuries to third parties, property damage, or other adverse consequences or outcomes, whether foreseeable or not, whether caused by negligence or otherwise, including without limitation negligent decontamination or rescue operations. By signing this Release, I understand I may be giving up legal rights that I or others claiming through me may claim to have now or in the future and I am freely and voluntarily entering into this Release. In so doing, I hereby specifically waive the provisions of Section 1542 of the California Civil Code Section 1542, which provides as follows:

A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release and that if known to him or her, would have materially affected his or her settlement with the debtor or released party.

This Release shall be binding upon me, my heirs and successors, assignees, personal representatives, and executors. This Release shall be governed by and construed according to the laws of the State of California, without regard to any conflicts of law principles. If any provision of this Release is deemed invalid, illegal, or unenforceable, it shall not affect the enforceability of any other term or provision of this Release. Rather, the invalid, illegal, or unenforceable provision shall be modified so that it is valid, legal, and enforceable and to the fullest extent possible, reflect the intention of the parties.

I HAVE READ THIS WAIVER & RELEASE OF LIABILITY IN ITS ENTIRETY, FULLY UNDERSTAND ITS TERMS, INCLUDING THAT I AM GIVING UP SUBSTANTIAL RIGHTS. I SIGN THIS DOCUMENT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME, AND INTEND BY MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT PERMITTED BY LAW.
PLEASE INDICATE HERE WHETHER YOU ARE OVER THE AGE OF 18 (Y/N) *
COVID-19 Waiver Signature of Parent/Guardian *

Clear
Printed name of person signing *
Date *
Participant Name (full legal name): *
Medical & Trip Declaration
Medical: As the parent/legal guardian of {fullName3}, I authorize any adult acting on behalf of Friendship Circle Los Angeles to hospitalize or secure treatment for my child and I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Friendship Circle personnel will try, but are not required, to communicate with me prior to such treatment.

Trips and Outings: I hereby give permission for my child/self, {fullName3} to attend and participate in all trips and outings organized as part of the program by Friendship Circle.
Medical & Trip Agreement: Parent/Guardian Signature *

Clear
Commitment to Safety & Well-Being
Friendship Circle provides very special and unique opportunities for volunteers, special friends and their families to enrich the lives of each other. In doing so, participants might encounter new and sometimes challenging situations. Thus, it is imperative to set expectations at the beginning so that volunteers, special friends, and parents understand what they can expect. Therefore, volunteers, special friends, and their families must each certify and agree by signing below that they:
- Understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct;
- Understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for me and/or my child to participate in this activity;
- Acknowledge the risk of injury from the activities involved in the Friendship Circle events or program and knowingly and freely assume all such risks;
- Will not allow me/my child to participate in any activity that I believe me and/or my child cannot perform in accordance with the Friendship Circles activities’ instructions or in a safe manner;
- If I observe any significant hazard during my child's participation in any Event, I will stop participating in the event and inform the Friendship Circle of such hazard immediately;
- Release Friendship Circle, the directors, board, officers, activity coordinators, and all employees, volunteers, related parties, and other organizations associated with the activity from any and all claims or liability arising out of this participation provided that care was taken to ensure safety;
- In case of an emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me/my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.
I give Friendship Circle permission to use my or my child's name, image, likeness or recording in connection with any promotional materials including, but not limited to, brochures, advertising and broadcasts. *

Yes No
Commitment to Safety & Well-Being: Parent/Guardian Signature *
Choose From Our Programs

All FCLA programming is in-person.
Friends @ Home Program

Connect with a teen or adult volunteer once a week for an hour of friendship, fun and camaraderie! These meet-ups can be arranged to accommodate a wide variety of schedules. For: Children & young adults ages 6+
Would you like your child to join the Friends @ Home Program?

Yes No
1st Choice: Day of the Week & Time
2nd Choice: Day of the Week & Time
Any pets owned? If yes, which pets?
If none, indicate "none"
Friends @ Home Respite Agreement

It is our pleasure to provide you with your Friends at Home service. However, it is necessary for a parent/guardian to assume responsibility and oversee activities shared together:

I/we agree that a parent/legal guardian will be at home at all times while volunteers are with my/our child.

I/we release the Friendship Circle, its providers, and administrators, from all liability for any incident that affects the health, welfare, or safety of {fullName3} in the provision of such service.
Friends @ Home Code of Conduct

As a parent of a child who has special needs participating in the Friendship Circle:
- I understand that Friendship Circle will match my child with either a preteen/teenage or adult volunteer.
- I understand that, it is necessary for me, as parent(s)/guardian(s) to assume full oversight and supervision responsibilities with respect to all activities Friendship Circle’s assigned teen mentor(s) share(s) with my child in connection with his/her participation in the program.
- I agree to respect the privacy of all participants of the Friendship Circle and to keep personal information confidential.
- If someone gets hurt or some other incident occurs during a Friendship Circle program, it is my responsibility to immediately report the occurrence to Friendship Circle staff.
As an express precondition of your child’s admission into the program, this parental consent form must be signed and returned to the Friendship Circle. Execution of this parental consent form serves as your acknowledgement: (1) of the critical importance Friendship Circle places on your agreement to at all times have at least one parent/guardian “on premises” during the entirety of each program related visitation; and (2) that the parent/guardian takes full responsibility for everything that transpires during the visit and exempts Friendship Circle from any responsibility or liability; and (3) the failure to abide by this requirement may, in the exercise of Friendship Circle’s sole and absolute discretion, result in the termination of all further program related visitations with your child.

I have carefully read and agree to abide and be bound by all additional rules and policies in the Friendship Circle Handbook and any additional rules pertinent to specific events.

I give my child permission to participate in Friendship Circle. I understand that participation in Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and give consent for myself and/or my child to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide and be bound by all applicable rules and policies as set forth in the Friendship Circle Friends @ Home Handbook, as it may be modified from time to time and any additional rules pertinent to specific events. I understand that this local Friendship Circle is independently owned, operated and controlled. I release the Friendship Circle and its employees, directors, officers, and volunteers as well as its affiliates and all other organizations associated with Friendship Circle from any and all claims or liability arising out of this participation.
Respite Agreement & Code of Conduct Signature

Clear
Release to Perform a Background Check (For Friends @ Home)

I hereby grant the Friendship Circle of Los Angeles permission to perform a background check on me as required by the law. This information will be kept confidential.
Mother's Full Legal Name

First Name Last Name
Mother's Date of Birth

Month Day Year
Date
Mother's Social Security Number
If applicable. If NOT applicable, please just enter "not applicable".
Signature

Clear
Father's Full Legal Name

First Name Last Name
Father's Date of Birth

Month Day Year
Date
Father's Social Security Number
If applicable. If NOT applicable, please just enter "not applicable".
Signature

Clear
Torah Social
Sunday mornings come to life at an innovative program filled with Jewish educational, social and recreational fun. Peers and participants pair up to enjoy the experience together!

Torah Social:

For: Children and young adults with special needs, Ages 5+
Date: On 22 Sundays, September 12, 2021 - June 12, 2022
Time: 9:15am-1:00pm

Torah Social will be taking place in two locations:

Division A: Girls of all ages and boys 5-11

Location: Friendship Circle of Los Angeles

1952 S. Robertson Blvd.

Los Angeles, CA 90034

Division B: Boys ages 12 and up

Bais Chaya Mushka

9051 W. Pico Blvd.

Los Angeles, CA 90035

Please contact Morah Doonie Mishulovin if you have any questions: Doonie@fcla.org
Torah Social Participation (select your option)

Yes - I'm interested in Torah Social Not participating in Torah Social
My child will be attending Division:

A - Girls of all ages and boys 5-11 B - Boys ages 12 and up
Holiday Programs

The Friendship Circle Holiday Celebrations allow the entire family to celebrate together in a comfortable setting. Volunteers are on hand to ensure that the event meets the particular needs of the children. Innovative activities bring the warm and joyous feelings of the holidays to the children and their families. (All Programs are free)
Rosh Hashanah Festival:

For: Children and young adults who have special needs & their families

Date: Sunday, August 29, 2021

Time: 1:00pm-3:00pm

Location: Friendship Circle of Los Angeles

Chanukah Bash:

For: Children and young adults who have special needs & their families

Date: Tuesday, November 30, 2021

Time: 5:30pm-7:30pm

Location: Friendship Circle of Los Angeles

Tu Bishvat Fun!

For: Children and young adults who have special needs & their families

Date: Sunday, January 16, 2022

Time: 1:00pm - 3:00pm

Location: Friendship Circle of Los Angeles

Purim Extravaganza!

For: Children and young adults who have special needs & their families

Date: Thursday, March 17, 2022

Time: 5:30pm - 8:00pm

Location: Friendship Circle of Los Angeles

Matzah Bakery

For: Children and young adults who have special needs & their families

Date: Sunday, April 3, 2022

Time: 12:30pm - 1:30pm

Location: Chabad of Westwood
I am Interested in:

Rosh Hashana Festival Chanukah Bash Tu Bishvat Fun! Purim Extravaganza! Matzah Bakery
Winter Camp

Yes I'm interested in Winter Camp 2021: Dates: 12/20/2021 - 12/24/2021 (Monday - Friday) and 12/27/2021 - 12/31/2021 (Monday - Friday): Total of 10 days.
Summer Camp

Yes I'm interested in Summer Camp 2022: Dates: TBD: Total of 15 days
Kick & Hoops

At Kicks & Hoops, kids and young adults with special needs get to experience the thrill of the sport firsthand! Coached by a professional and supported by a behaviorist, the children learn the rules of the game, develop teamwork and most of all, have fun!

For boys only, Ages 12 and up

Wednesday Nights 6:30pm-8:00pm

Location: Friendship Circle of Los Angeles

1952 S. Robertson Blvd.

Los Angeles, CA 90034

Any questions? Email Racheli at racheli@fcla.org
I'm interested in signing up my child for Kicks and Hoops

Yes I'm interested Not Interested
Girls' Scene

For girls only, Ages 12 and up

Monday Nights 6:30pm-8:00pm

Location: Friendship Circle of Los Angeles

1952 S. Robertson Blvd.

Los Angeles, CA 90034

Any questions: email Racheli at racheli@fcla.org
I'm interested in signing up my child for Girls' Scene

Yes I'm interested Not Interested
Programs for Parents
Interested?

Mom’s Torah & Tea. Mark Rosh-Chodesh, the Jewish new month, with a night out among fellow moms, delicious food you didn’t need to make and inspirational Torah thoughts. Date: 11/2/2021, 12/7/2021, 1/4/2022, 2/1/2022, 3/1/2022, 4/4/2022, 5/3/2022, 5/31/2022: Time: 8:00-9:00pm Spa Night. An exclusive event for Friendship Circle moms to pamper the mind, body and soul. Date: Tuesday, 2/15/2022. Time: 7:00-10:00pm.
Email for receiving receipts and confirmation of this application: *
example@example.com
Summary & Submit

Our fees have increased! But we are self-Determination Friendly!
Fee Schedule:
- Torah Social: $2,000
- Winter Camp (2 weeks): $1,300
- Summer Camp (3 weeks): $1,950
- Kicks & Hoops: $1,500
- Girls' Scene: $1,500
No Fee:
- Friends @ Home
- Holiday Programs
- Saturday Night Fun
- Parent Programs
I/we would like to help sponsor the activities of another child in need:
Optionally enter a donation amount to be added to the subtotal above
Total Amount Due for Torah Social
Total Amount Due for Kicks and Hoops
Total Amount Due for Girls Scene
Total Amount Due for Winter Camp 2021
Total Amount Due for Summer Camp 2022
TOTAL AMOUNT DUE
I would like to pay by:

Credit Card: form to follow below PayPal: donate@fcla.org Venmo: FCLAVen I will send a check I will get funds through Regional Center I need financial aid

Please make checks payable to to Friendship Circle of Los Angeles and mail to 1952 S. Robertson Blvd, Los Angeles CA 90034.
For billing matters or scholarship requests please email our billing department/scholarship committee at billing@fcla.org. No one will be turned away for a lack of funds.
Should be Empty:

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

New Child Information

Returning Participant Update Form

Parents/Guardian Information

Medical Information

Insurance Information

Emergency Contact Information

Medical & Trip Declaration

Commitment to Safety & Well-Being

Choose From Our Programs

Friends @ Home Program

Torah Social

Holiday Programs

Programs for Parents

Summary & Submit