Sign your child up Today!


Child Info





Child's First Name:


Last Name:


Male Female



Birth Date


Home Phone Number






Postal Code










Parents Info





Father's Name


Mother's Name

Father's Cell Phone


Mother's Cell Phone

Father's E-Mail


Mother's E-Mail

Parental Status

Married Divorced


If divorced
Child lives with

Synagogue Affiliation:




Important Info


Does your child occasionally exhibit
any of the following behaviors?


Biting Cursing Grabbing Hitting
Kicking Pulling Hair Other

What is your best method of handling the situation?


Other things you would like to tell us about your child


Medical Info





Emergency Contact Name


Phone Number





Please list any allergies


Medical/ Diagnosis/ Concerns:


















Friends @ Home


When would you like the volunteers to come and visit your home?


1st choice

2nd choice

Do you prefer having:

New Volunteers
Same Volunteers as Last Year.

Names of previous volunteers:


I permit my child’s photos to be used for Friendship Circle publicity purposes

yes no

What are you expectations of Friendship Circle?


What are some of the changes you hope to see in you child?

Would you like the volunteer to concentrate on sibling involvement?


Are there any special activities that should be worked on or introduced?

Are there any concerns regarding the adaptive level of your child while interacting with new persons or in new situations?


Program Selection

You can check off which programs you're interested in and would like to hear more about. We won't charge you before confirming charges with you.

Friends @ Home (Volunteer must consent to being alone with your child at home, if you won't be home.) Free of charge.


Sunday Circle: $410, early bird fee before September 10- $375  10:45-12:45

Mom's Club. Free of charge.


September 17 HIGH HOLIDAY PROGRAM 2 Hour Drop Off program for Friendship Circle Children and Siblings cost $5 a child

Family Holiday Programs, Dates coming.


Holiday Cooking Club: COST: $8 for 1 class, Age: 8+ 








Payment Details:





Total Amount


Card Type

Visa Master Card

Card #


Name on card