SIGN YOUR CHILD UP TODAY - CLICK HERE - Chabad Lubavitch of Ontario
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Sign your child up Today!

     
         

Child Info

 

 

 

 

Child's First Name:

 

Last Name:

 

Male Female

 

Age:

Birth Date

 

Home Phone Number

Address

 

City

Province

 

Postal Code

School

 

 

 

 

 

 

 

 

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

 

 

 

Cell

Please list any allergies

 

Medical/ Diagnosis/ Concerns:

 

 

 

 

 

Siblings

       

Name

 

Age

Name

 

Age

Name

 

Age

         

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+ 

 

 

   

comments:

 

 

 

Payment Details:

 

 

 

 

Total Amount

 

Card Type

Visa Master Card

Card #

 

Name on card

Exp

 

 

 

 

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