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Age (This form is for ages 5-17 ONLY) *
Child School *
Child's Grade *
Child's Preferred Language *
Child's Race *
Child's Ethnicity *
Relationship to child *
Occupation *
Primary Email Address *
Primary Phone Number *
Relationship to Child
Occupation
Secondary Email Address
Secondary Phone Number
Who does the child live with? *
Authorized Person #1 Phone Number *
Authorized Person #2 Phone Number *
Other please specify
Does your child have any allergies or food allergies? If so, please provide details. *
Please provide instructions for emergency medicine. *
What does your child enjoy doing the most? Please list preferred activities, interests or hobbies. *
What makes your child upset? Please list what might trigger frustration or challenging behaviors. *
When was the date of the last physical aggression incident? *
Please describe in full detail what the incident looked like, including any triggers and how the behavior was addressed? *
Does elopement occur situational or repetetive? *
Please describe an example of the elopement occuring? *
Please describe in detail what the self-injurious behaviors look like, how often they happen, and how you currently manage or respond to them. *
Please share as much detail as you can about your child’s behaviors. This information helps our staff and therapists understand and support your child better. If there are any calming or de-escalation strategies that work well at home, please include those too. *
Phone *
How did you hear about Friendship Circle? *
NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF THE FRIENDSHIP CIRCLE OF MIAMI, INC. USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM, YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM THE FRIENDSHIP CIRCLE OF MIAMI, INC. IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND THE FRIENDSHIP CIRCLE OF MIAMI, INC. HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
I, (print name) for myself, my heirs and personal representatives, hereby assume all liabilities, risks, injuries and hazards to my child/children, (print name of child) , incidental to, or as a result of, participation in the programs and activities of The Friendship Circle of Miami, Inc., including, but not limited to, engaging in activities with special needs children, learning in a classroom environment, participating in outdoor events such as: hiking, swimming, horseback riding, exploring, sports, martial arts, day trips including transportation TO AND FROM the said activity. I freely acknowledge the fact that
this/these program(s) may have, and/or do involve, physical contact or other conditions or factual circumstances where physical or other injuries, including but not limited to death, may occur, and that transportation to and from said event could involve the potential for an automobile, or other, accident. As legal guardian and/or natural parent of the above referenced child/children, I do hereby waive, release and agree to indemnify and hold harmless The Friendship Circle of Miami, Inc., their officers, agents, employees, volunteers, the organizers, sponsors, activity supervisors, co-sponsoring organizations and participants for any claim or cause of action against them for personal injury including death, and property damage resulting from an inherent risk in the activity or program. These inherent risks means those dangers or conditions, known or unknown, which are a characteristic of, intrinsic to, or an integral part of the activity and which are not eliminated even if The Friendship Circle of Miami, Inc., their officers, agents, employees, volunteers, the organizers, sponsors, activity supervisors, co-sponsoring organizations and participants, acts with due care in a reasonably prudent manner; and includes, but is not limited to: failure to warn the natural guardian or minor child of an inherent risk; and the risk that the minor child or another participant in the activity may act in a negligent or intentional manner and contribute to the injury or death of the minor child. I, as legal guardian and/or natural parent of the above referenced child/children, assume all risk of injury, liability, and loss arising from my child/children’s participation or presence at said activity. I acknowledge that The Friendship Circle, Inc., will not assume any costs relating to any injury while my child/children are involved in this activity, or from transportation to or from this activity.
This Waiver, Release and Hold Harmless/Indemnification Agreement is in consideration of The Friendship Circle of Miami, Inc. permitting my child/children’s participation in the activity or program at issue and in further consideration of The Friendship Circle of Miami, Inc. not requiring self-funded liability insurance coverage on my part as a condition precedent to my child/children’s participation in the activity. I, as legal guardian and/or natural parent of the aforesaid child/children, freely and voluntarily assume all risk of loss or injury arising from my child/children’s participation in the activity whether due to my negligence, my child/children's negligence, or the negligence or intentional acts of others. I acknowledge that, absent this Release and indemnification, The Friendship Circle of Miami, Inc., or other sponsors of the activity would not have offered me, or my child/children, the access to the activity because of unacceptable exposure to civil liability claims and/or lawsuits, or the expense of providing a program that is risk-free. By signing this waiver, I agree to indemnify any and all employees and volunteers of The Friendship Circle of Miami, Inc. for any and all damages which result from any and all acts or omissions, including negligence, in whole or in part, on the part of any employee or volunteer of The Friendship Circle of Miami, Inc.
I have read and understood this document and sign it freely and knowingly, intending that it shall be fully operative and effective in all respects and that it waives legal rights to which I, or my child/children, might
otherwise be entitled if my child/children are hurt or suffer loss during his/her/their participation in that activity.
YOU MUST CAREFULLY READ THIS DOCUMENT BEFORE SIGNING IT. YOU ARE WAIVING OR RELEASING VALUABLE LEGAL RIGHTS.
YOU ARE ADVISED TO SEEK THE ADVICE OF AN ATTORNEY IF YOU DO NOT FULLY UNDERSTAND THIS DOCUMENT.