1Participant2Programs3Payment4Signature HiddenSubmission ID HiddenDebug Thank you for your registration, please complete your Program Registration below.Form Code Registration is for* Participant Sibling The FC Hebrew School provides a Hebrew and Judaic education for children with special needs. Teachers will focus on engaging the child’s sense of Jewish identity through exciting, hands-on learning. Each student will learn at their own pace with individualized curriculums. No previous Judaic instruction necessary, teachers will design curricula to meet each student’s current level and learning style.Applicant's InfoApplicant's Name* First Last Birth Date*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Applicant requires* Teen volunteer Trained adult aide – There will be an additional cost for the aide per program I will supply my own aide – no additional cost Independent Age*Name of Parent/Guardian* Parent/Guardian Email* Parent/Guardian Cell*Is the natural mother of the child Jewish?* Yes No Were there any conversions or adoptions in the family?* Yes No Please give details of the conversion/adoption* Friends@Home Jr.Program begins on September 6, 2022 and concludes on June 16, 2023.Register for Friends@Home Jr. Register for Friends@Home Jr. Friends@Home Jr. When would you like volunteers to come and visit your home?First Choice*SundayMondayTuesdayWednesdayThursdayFridayTime* : Hour Minutes AM PM AM/PM Second Choice*SundayMondayTuesdayWednesdayThursdayFridayTime* : Hour Minutes AM PM AM/PM Would you be interested in having* the same volunteer new volunteers Please note: To help protect the safety of those involved, background checks will be required of everyone in the household who is over 18, prior to starting Friends@HomeProgramsJoshua’s Club – Torah TimeSundays, Sundays 10am-11amPrice: $60September 18October 2November 20February 19May 28June 11Register for Joshua’s Club – Torah Time Register for Joshua’s Club – Torah Time Joshua’s Club – Torah Time Price: Skill Building #210:00am-12:00pmPrice: $280Deposit: $50 (non-refundable); applied to total costAide Fee: $560Thursday, February 2Thursday, February 9Thursday, February 16Thursday, February 23Thursday, March 2Thursday, March 9Thursday, March 16Thursday, March 23Thursday, March 30Thursday, April 20Thursday, April 27Thursday, May 4Thursday, May 11Thursday, May 18Thursday, June 1Thursday, June 8Thursday, June 15Wednesday, June 22Wednesday, June 29Register for Skill Building #2 Register for Skill Building #2 Skill Building #2 Price: Skill Building #2 Aide Fee Price: Culinary and Art #2Tuesdays, 11:00 am - 1:00 pm Price: $325Deposit: $50 (non-refundable); applied to total costAide Fee: $520February 7February 14February 28March 14March 21March 28April 18April 25May 9May 16May 23May 30June 6Register for Culinary and Art #2 Register for Culinary and Art #2 Culinary and Art #2 Price: Culinary and Art #2 Aide Fee Price: Joshua’s Club- Social #2Tuesdays, Tuesdays 6:30-7:30pmPrice: $70February 7February 21March 14March 28April 25May 9June 6Register for Joshua’s Club- Social #2 Register for Joshua’s Club- Social #2 Joshua’s Club- Social #2 Price: Bowling #2Thursdays, 6:30-8:00pmPrice: $80Deposit: $50 (non-refundable); applied to total costAide Fee: $120June 1June 15July 6July 20Register for Bowling #2 Register for Bowling #2 Bowling #2 Price: Bowling #2 Aide Fee Price: Outdoor SportsMondays, 4:30- 5:30pmPrice: $15 per dateAide Fee: $25Register for Outdoor Sports June 5 June 12 June 19 June 26 July 10 July 17 July 24 Outdoor Sports Price: Outdoor Sports - QuantityOutdoor Sports Aide Fee Price: Open Art and PlayWednesdays, 4:30-5:30pmPrice: $15 per dateAide Fee: $25Register for Open Art and Play June 7 June 14 June 21 June 28 July 5 July 12 July 19 July 26 Open Art and Play Price: Open Art and Play - QuantityOpen Art and Play Aide Fee Price: Culinary and Art #3Tuesdays, 11:00 am - 1:00 pm Price: $150Deposit: $50 (non-refundable); applied to total costAide Fee: $240June 13June 20June 27July 11July 18July 25Register for Culinary and Art #3 Register for Culinary and Art #3 Culinary and Art #3 Price: Culinary and Art #3 Aide Fee Price: Skill Building #3Thursdays, 10:00am-12:00pmPrice: $120Deposit: $50 (non-refundable); applied to total costAide Fee: $210June 15June 22June 29July 6July 13July 20Register for Skill Building #3 Register for Skill Building #3 Skill Building #3 Price: Skill Building #3 Aide Fee Price: Movie Night #2Tuesdays, 6:30-8:00pmPrice: $30Deposit: $50 (non-refundable); applied to total costJune 27July 11Register for Movie Night #2 Register for Movie Night #2 Movie Night #2 Price: Form CalculationsDeposit Amount TotalDepositRemainder After DepositHalf PaymentQuarter PaymentProgram Summary Total ScholarshipsI would like to request a partial Scholarship I would like to request a partial Scholarship How much would you be comfortable paying?* I will make a team and try to raise money for the FC Walk I will make a team and try to raise money for the FC Walk Payment{:111} Deposit $0.00 Balance $0.00 Total $0.00 Deposit Amount Total $0.00 Payment Options* Pay in full Pay in installments Payment Schedule* $0 on Jul 4 and again on Sep 4 $0 on Jul 4 and again on Sep 4, Nov 4, Jan 4 Total Charged Today$0 Total Charged Today$0We will contact you shortly regarding the scholarship amount.Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Billing 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment Summary {:111}In-Person ProtocolCOVID Procedures* I have reviewed and agree to the following procedures:Hidden My child/teen/young adult will wear a mask covering the nose and mouth for duration of the program. OR My child/teen/young adult is unable to wear a mask but is fully vaccinated or has tested positive for antibodies in the last 3 month * I/my child will stay home if they or anyone in my household is not feeling well. Hidden I/my child will stay home if they or anyone in my household has been exposed to or has COVID-19. Hidden I will inform Friendship Circle if my child or myself tests positive for COVID-19. SignatureNotify on Non Attendance* In the event that my child is unable to attend any of the above selected programs, I will notify the Friendship Circle. Who is filling out this form?* Mother Father Legal Guardian Signature*CommentsPhoneThis field is for validation purposes and should be left unchanged. Δ
