Child's Info      

Child's Name

Birth Date 
 

 /  /  
  Month       Day          Year

Address

City

State

Zip

Phone Number

Father's Info      

Name

Occupation

Cell Phone
E-Mail
 
     
Mother's Info
 
 
 
Name
Occupation
Cell Phone
E-Mail

 

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 
(other then parent)

Phone
 
 

Cell

 
Please list any allergies
Please list any medical conditions that we should be aware of
 
When would you like volunteers to come and visit your home?

1st choice  
Day of the week

 

Time

 

 

2nd choice  
Day of the week

 

 

Time

 

 
Would you be interested in having  the same volunteers or   new volunteers
 
   
Respite Service Agreement  
It is our pleasure to provide you with our Friends At Home service, however it is necessary for a parent/guardian to assume responsibility to oversee activities shared together.
 
I/We  (Parent/Guardian) release the Friendship Circle, its providers and administrators, from all liability for any incident which affects the health, welfare or safety of  (child) in the provision of such service.

 



 $ 0.00

  
I allow my child's photos to be used for any and all Friendship Circle publicity purposes. 
 Yes 
 No

  
Please type the signature of the person filling out the form:
 
Signature of Mother / Guardian  Date: 
Signature of Father / Guardian  Date: 

 

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The Friendship Circle by The Sea
17315 West Sunset Boulevard
Pacific Palisades, CA 90272-4101
310-454-7783