1Applicant2Medical Info3All About Me4Parents5Consent HiddenSubmission ID HiddenDebug Registration is for* Participant Sibling Participant's InfoParticipant's Name* First Last Gender* Male Female Birth Date*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Grade 2023-24* Temple Affiliation* Participant Photo*Accepted file types: jpg, gif, png, jpeg, Max. file size: 50 MB.Participant Email Address Cell Number Cell Carrier Cell Carrier* 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?* Yes No Applicant is allergic to Hay Fever Poison Ivy/Oak 3. Insect Stings Food Penicillin Other Drugs Other Food Allergies* Drug Allergies* Other Allergies* HiddenNumber of Allergies CheckedDescribe reaction and treatment*Does applicant require an EpiPen?* Yes No If 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. HiddenMedicationsHiddenWill the applicant be taking medications during any FC program?* Yes No Please 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.HiddenMedications Medication Name Dosage Take at what times Reason for Taking Actions Edit Delete There are no Medications. Add Medication Maximum number of medications reached. HiddenMedication 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* HiddenNumber 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 verbal I am not verbal What is the best way to communicate with me?FoodFood* I can eat independently I need assistance eating Are there any food limitations or a special diet?* Yes No Please specify*BehaviorI Like*I don't like*If I need to be redirected, this is what helps meBathroomBathroom* I can go independently I need assistance I am not toilet trained Please Describe*SwimmingI can swim in shallow water* With assistance Without assistance Other Other: I can swim in deep water* With assistance Without assistance Other Other: Other Swim Info about me Parent/Guardian InfoResponsible Party* Mother Father Guardian Responsible Party's InfoMother's InfoFather's InfoGuardian's InfoName* First Last Occupation Cell Number*Cell Carrier* E-mail* Birthdate*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent’s Status* Married Widowed Divorced Separated Would you like to receive emails from our FC parent network?* Yes No Other 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?* Yes No In-Person ProtocolCOVID Procedures* I have reviewed and agree to the following procedures:Hidden* I/my child will stay home if they or anyone in my household is not feeling well. Code of Conduct Parent/Guardian Signature Actions 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.* Yes No Who is filling out this form?* Mother Father Legal Guardian * I hereby give permission to the Friendship Circle-LifeTown administration to take whatever medical measures they deem necessary for my child in the event of a medical emergency. Signature*CommentsCommentsThis field is for validation purposes and should be left unchanged. Δ
