Child Registration Participants Name * First Name Last Name Gender * Male Female Age * MM DD YYYY School * Medical Diagnosis * Name of Mother * First Name Last Name Name of Father * First Name Last Name Mothers Email Address * Mothers Cell * (###) ### #### Fathers Email * Fathers Cell * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Are you? * Father Mother Guardian Religious Affiliation * How did you find out about Friendship Circle? Friend Doctor/Therapist Car Magnet Friendship Walk Internet Other All new families interested in joining the Friendship Circle will have an opportunity to meet with a staff person to discuss the programs that are available. Any questions or concerns can be addressed at this time. Once you have discussed the specific needs of your child, our volunteer coordinators will work on matching an appropriate volunteer with your child. What time works best for you? What day works best for you? Sunday Monday Tuesday Wednesday Thursday Do you give permission for the Friendship Circle to use pictures of your child in social media and other news sources (once part of the program)? * Yes No Yes, but please approve the picture with me beforehand. Question & Comments Thank you for registering your child. One of our staff members will be in contact with you in the next 24-48 hours. Welcome to the Friendship Circle Family!
