1 Applicant2 Medical Info3 All About Me4 Parents5 Consent Submission IDDebugRegistration is for*ParticipantSiblingParticipant's InfoParticipant's Name* First Last Gender*MaleFemaleBirth Date*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Grade 2019/20*Temple Affiliation*Participant Photo*Accepted file types: jpg, gif, png, jpeg.Important InfoDoes the participant occasionally exhibit any of the following behaviors? Biting Grabbing Kicking Cursing Hitting Other Other behavior*What is your best method of handling the situation?*Other things you would like to tell us about the participant AllergiesDoes applicant have any allergies?*YesNoApplicant is allergic to Hay Fever Poison Ivy/Oak 3. Insect Stings Food Penicillin Other Drugs Other Food Allergies* Drug Allergies* Other Allergies* Number of Allergies CheckedDescribe reaction and treatment*Does applicant require an EpiPen?*YesNoIf applicant requires an EpiPen, please list all instructions*EpiPen Authorization* Should the applicant have an allergic reaction, I give permission for staff to administer the EpiPen. MedicationsWill the applicant be taking medications during any FC program?*YesNoPlease list all prescription and non‐prescription medications the applicant will need administered during programs. Include the medication name, prescribing physician, physicians’ phone number, and the dosage instructions. When you check‐in at programs, please provide all medications (in their original packaging that identifies the prescribing physician (if prescription drug), the name of the medication, the dosage, and frequency of administration.Medications Medication Name Dosage Take at what times Reason for Taking Edit Delete There are no Medications. Add Medication Maximum number of medications reached. Medication Authorization* I hereby authorize the staff to administer these medication(s) per physicians orders at FC programs. Medical HistoryDoes the applicant have a history of or is prone to any of the following Recent injury, illness or infectious disease Chronic or recurring illness Asthma Frequent Ear Infections Seizure Disorder or Convulsions Heart Defect/Disease Hypertension Bleeding/Clotting Disorders Diabetes Joint problems (knees, ankles) Fractures Frequent Headaches Head Injury Eating Disorder Diarrhea or constipation Frequent Stomachaches Other Other*Number of Medical History CheckedPlease provide explanation for any checked items*Physical Activities to be limited or restricted while at FC ProgramsEmergency Contact Name (other than parent)* First Last Emergency Cell* All About Me!Important information that my volunteer needs to know.CommunicationCommunication*I am verbalI am not verbalWhat is the best way to communicate with me?FoodFood*I can eat independentlyI need assistance eatingAre there any food limitations or a special diet?*YesNoPlease specify*BehaviorI Like*I don't like*If I need to be redirected, this is what helps meBathroomBathroom*I can go independentlyI need assistanceI am not toilet trainedPlease Describe* Parent/Guardian InfoResponsible Party*MotherFatherGuardianResponsible Party's InfoMother's InfoFather's InfoGuardian's InfoName* First Last OccupationCell Number*Cell Carrier*E-mail* Birthdate*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent’s Status*MarriedWidowedDivorcedSeparatedWould you like to receive emails from our FC parent network?*YesNoOther Parent's InfoMother's InfoFather's InfoOther Guardian's InfoName* First Last Occupation*Cell Number*E-mail* SignatureWill you be sending a caregiver / aide / nurse?*YesNoCode of Conduct Parent/Guardian Signature Edit Delete There are no Code of Conducts. Add Code of Conduct Maximum number of code of conducts reached. Please read and sign the code of conductI allow applicant's photo to be used for any and all Friendship Circle publicity purposes.*YesNoWho is filling out this form?*MotherFatherLegal GuardianSignature*CommentsCommentsThis field is for validation purposes and should be left unchanged.
