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2026/27 Child Registration Form
(Ages 5-17)

2026/27 Child Registration Form (Ages 5-17)

Please complete this form in it’s entirety and be as detailed as possible as this is the information we share with our program staff and therapists. Some of our programs partially rely on grants for funding, and certain pieces of information are collected for the purpose of required grant reporting. Client privacy protection will be observed in accordance with those rules set forth in the Health Insurance Portability and Accountability Act (HIPPA).

Child's Information:

Child's Name
Are you a new or returning participant?
Have you and your child completed the intake meeting?
Has your child participated in programs/camp in the last 3 years?
Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.
Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.
Child's Race
Select all that apply
Child's Ethnicity

Parent/Guardian Information:

Primary Guardian or Caretaker
Primary Email Address
Primary Address
Secondary Guardian or Caretaker
Who does the child live with?

Authorized People for Pick up & Drop off:

Authorized Person #1 (Pick-up and Drop-off)
Authorized Person #2 (Pick-up and Drop-off)

Medical/Behavioral Information

Medical/Health Related Conditions Please select all that apply
Does your child have any food allergies/dietary restrictions?
Does your child have any OUTSIDE or ENVIRONMENTAL allergies?
Does your child carry emergency medicine on them and will be bringing to programs? (Ex: Epi-pen or Seizure Spray)
If you child carries an EPI- PEN you MUST carry Benadryl to administer as well. Friendship Circle Miami WILL ONLY administer NASAL SEIZURE SPRAY AND EPI-PEN, we WILL NOT administer daily medications, NSAIDS or rectal seizure spray. In the event of a seizure or epi-pen is required 911 will be called as well as Primary Contact.
Is your child potty trained?
If you indicated that your child wears diapers or needs assistance, we regret that we are unable to provide assistance with going to the bathroom. To ensure your child’s needs are properly met, attendance with a personal aide is necessary. We appreciate your understanding and cooperation.
Please list preffered activities, interests or hobbies.
Please list what might trigger frustration or challenging behaviors.
Please specify any behaviors your child may exhibit or any new behaviors that may be occuring.
Please let us know what fidget/sensory toy or any preferred items your child likes so we can try to have those items available here for them.
Is your child part of UM CARD?
Does your child currently receive behavioral therapy services?
Will your child be attending programs with their own Registered Behavior Technician (RBT)?

Scholarships & Financial Assistance

Scholarship opportunities are available. If you would like to be considered for scholarship/ financial assistance, please indicate your median household income below. Once your form is reviewed, an email will be sent to you with a scholarship code to enroll for programs.
Do you need to apply for scholarship/financial assistance for the current school year?

Discover Friendship Circle's Project Lifeline - Your Partner in Supporting Children with Special Needs

Navigating the many services available for children with special needs can feel overwhelming—that’s where Project Lifeline steps in. Our dedicated Social Worker works closely with your family, beginning with a thorough assessment to understand your child’s unique strengths and needs. Together, we’ll develop a personalized plan connecting you to the right programs and resources tailored just for you.

With ongoing, individualized support, Project Lifeline helps you access community services that truly make a difference for your child and family. Best of all, all our services are provided completely free of charge.

Let us help you find the support your family deserves—reach out today to learn more about how Project Lifeline can make a difference in your journey.

To learn more, please visit Project Lifeline

I am also interested in the following programs:
Connect with other parents, gain support, and find resources in a welcoming space designed to empower and strengthen families on their special needs journey.

Waivers & Policies:

I hereby grant permission for photographs of my child, without any identifying information, to be used by Friendship Circle and its partners for publicity related to Friendship Circle activities.
We sincerely appreciate your support in helping us share the impact of our programs with the community. By allowing us to highlight your child’s talents, you contribute to keeping our costs low and our marketing efforts authentic and effective.

Liability Waiver:

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,  for myself, my heirs and personal representatives, hereby assume all liabilities, risks, injuries and hazards to my child/children, 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.

Clear Signature

I Understand: By typing my name below, I understand that the Friendship Circle of Miami, Inc, including without limitation, any of its directors, teachers, employees, or agents, and including any volunteer, shall not be liable to any party for injury or damage, whether from acts of negligence or otherwise, in any way attributable to or in connection with such activities or field trips. I understand and consent that, if there is imminent risk of physical injury to the child or any other person, the use of restraint or seclusion by a trained professional may be administered. I will not hold The Friendship Circle or any of its agents responsible for any injury that may occur due to restraint or seclusion. In case of medical emergency requiring immediate care, I authorize paramedics to take my child to the nearest hospital. I release The Friendship Circle, its providers and administrators, from all liability for any incident which affects the health, welfare or safety of my child(ren) in the provision of such service. I give permission for my child(ren) to participate in off-site field trips as scheduled. You will be advised of such field trips in advance.

Clear Signature

By enrolling my child in the program, I, as the parent or legal guardian, acknowledge and understand that the program serves special needs children with diverse backgrounds, treatments, symptoms, and diagnoses, which may occasionally result in behaviors that pose an imminent risk of serious injury to the child or others. I further acknowledge that, in such emergency situations, the program staff may be required to employ physical restraint to ensure the safety and well-being of the child being restrained, other child participants in the program, staff members, contractors, volunteers, and affiliates.

I hereby consent to the use of physical restraint by program staff under the following conditions: 

  • Emergency Situations Only: Physical restraint shall only be used when all positive behavior interventions and supports have been exhausted, and the program has determined that there is an imminent risk of serious injury to the child or others, as required by applicable law.

[Fla. Stat. § 1003.573].

  • Least Restrictive Means: Any physical restraint employed shall impose the least possible restrictions consistent with its purpose, shall be executed with the full intent to not cause physical injury, and shall be discontinued as soon as the threat of harm has dissipated.

[Fla. Stat. § 1003.573, Fla. Stat. § 393.13]. 

  • Prohibited Uses: Physical restraint shall not be used as punishment, for the convenience of staff, or as a substitute for a behavior support plan.

[Fla. Stat. § 1003.573, Fla. Stat. § 393.13]. 

  • Staff Training and Qualifications: I understand that staff and/or contractors authorized to use physical restraint will have received appropriate training in positive behavior interventions and supports, as well as in the safe and lawful application of physical restraint techniques.

[Fla. Stat. § 1003.573, Fla. Stat. § 393.13]. 

  • Documentation and Notification: I acknowledge that any incident involving the use of physical restraint will be documented in an incident report, which will include the circumstances leading to the restraint, the type and duration of the restraint, and any injuries sustained. I will be notified of such incidents in writing within 48 hours, and I will be provided with a copy of the incident report.

[Fla. Stat. § 1003.573, 65E-9.013 Restraint, Seclusion, and Time-Out].

  • Review and Prevention: Following any incident of physical restraint, the program will review the circumstances and, if requested, work with the child’s parents/guardians and/or the child’s medical professionals to implement and/or revise the child’s behavior support plan to minimize the likelihood of future incidents.

[Fla. Stat. § 393.13, 65E-9.013 Restraint, Seclusion, and Time-Out]. 

By signing this waiver, I acknowledge that I have been informed of the program’s policies and procedures regarding the use of physical restraint, and I consent to the use of such measures under the conditions outlined above. I further release the program, its staff, contractors, volunteers, and affiliates from liability for the lawful and appropriate use of physical restraint in accordance with this waiver and applicable laws.

Clear Signature

1. No Refund Policy
We are unable to provide refunds if a participant misses due to illness or does not participate in a scheduled activity. We appreciate your understanding and ask that you please refrain from requesting exceptions.

2. Medication and Creams
Staff are not permitted to administer medication or apply creams. Please take care of any necessary treatments before or after program hours. In the case of minor cuts or scrapes, we will clean the area with soap and water and provide a bandage.

3. Medical Emergencies
In the event of a serious medical emergency, such as a seizure or anaphylactic reaction, we will immediately call 911 and then notify parents. We do not provide medication except life-saving medication such as Epi-pen or Seizure spray.

4. Illness Policy
If your child is not feeling well, please keep them home and inform us. This helps protect the health and well-being of all paricipants, volunteers and staff. Specifically, please do not send your child to programs if they have a fever, persistent coughing, or green mucus, as these may be signs of a contagious illness. If a child becomes ill during the day, we will contact you to arrange for prompt pick-up. We appreciate your cooperation in helping us maintain a healthy environment for everyone.

5. RBT Support
If your child attends program with a Registered Behavior Technician (RBT), the RBT must remain with the child for the entire duration of the program/day.

Clear Signature
Parent's Name
Date / Time
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