25'-26' New Participant Application

BS"D
New Participant Application Form
My child or young adult is a:*

New ParticipantReturning Participant
Returning Participants, please use our Program Selection Form to update your information and make your program selections.
Please note: this form is only in addition to an intake meeting. We require a parent to attend an intake meeting before their child or young adult attends any programs.

To schedule an intake meeting, email Jen at jen@fcla.org.
New Participant Information
Full Name*

First NameLast Name
Hebrew Name
Your Jewish Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
School Attending*
Grade*
Today
Current Age of Participant
Are there any new behaviors we need to know about?

YesNo
Please Describe:
Participant Email (if applicable)
example@example.com
Home Phone*
Home Phone (if needs to be updated)
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Have you moved within the past year?

YesNo
New Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Status*
Participant Lives With*
How were you referred to us?
Parents/Guardian Information

Please fill in the information for at least one Parent/Guardian
Mother's Name*

First NameLast Name
Mother's Hebrew Name
Mother's Mobile Phone*
Mother's Mobile Phone (if needs to be updated)
Mother's Occupation*
Mother's Place of Employment
Mother's Work Address

Street Address

Street Address Line 2

CityState

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

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

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone (if different than child's)
Father's Mobile Phone*
Father's Mobile Phone (if needs to be updated)
Father's Occupation*
Father's Place of Employment
Father's Work Address

Street Address

Street Address Line 2

CityState

Zip Code
Father's Work Phone*
Father's Work Phone (if needs to be updated)
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 NameLast 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?*

YesNo
If YES, please provide details:
Are there any mental health or developmental concerns we should be aware of?*

YesNo
If YES, please provide details:
Is your child toilet trained?*

YesNo
Doctor*

First NameLast Name
Doctor's Phone Number*
Insurance Information
Insurance Carrier*
Policy Number*
Insurance Phone Number*
Have there been any changes in your child's medical condition/information within the past year?

YesNo
Please Provide Details:
Are there any changes in your child's insurance information within the past year?

YesNo
Please Provide Details:
Do you have new emergency contacts?

YesNo
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 NameLast Name
Emergency Contact #1 Mobile Phone*
Emergency Contact #1 Relationship to Child*
Emergency Contact #2 Name*

First NameLast Name
Emergency Contact #2 Mobile Phone*
Emergency Contact #2 Relationship to Child*
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, {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/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. *

YesNo
Commitment to Safety & Well-Being/Publicity: Parent/Guardian Signature*

Clear
Email address to receive application confirmation:*
example@example.com
Should be Empty:

New Participant Application Form

New Participant Information

Parents/Guardian Information

Medical Information

Insurance Information

Emergency Contact Information

Medical & Trip Declaration

Commitment to Safety & Well-Being