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24-25Adult Registration Form (Ages 18+)

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).

Participant's Name
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Primary Guardian
Primary address (Participant's residence)
Secondary Guardian
Authorized Person to pick up 1
Authorized Person to pick up 2
Medical/Health Related Conditions Please select all that apply
Is the participant potty trained?
Please specify any behaviors the participant may exhibit or any new behaviors that may be occuring.
Does the participant receive behavioral therapy?
Will the participant be attending with their own RBT/AID? If yes, we must have their Level 2 background and contract signed PRIOR to joining programs.
Are you a new or returning partcipant?
Scholarships

Scholarships are available. If you would like to apply for a scholarship, please indicate so below. Please select all programs you're interested in. We will review your form and send an invoice via email..

Do you need to apply for scholarship assistance for 24-25 year?
Which programs would you like to sign up for?
Annual membership: Includes ALL programs September - May : No School Fun Days, and Adult Social Group.
September - May Does not include Winter/Spring/Summer Camp, or Summer Programs)
Adult Social Group
Meets 2 Tuesdays 630 pm -8 pm and 1 Sunday 130 pm -430 a month. September - May
Movement Mondays
Mondays 4-5 pm Session 2: January - May
Art Circle
Mondays 5-4 pm Session 2: January - May
FC Band
Wednesday 5-6 pm Session1 September - December Session 2 January- May
Drama Circle
Wednesday 4-5 pm Session 2: January - May
I am also interested in the following programs:

Project Lifeline: Assisting families with community resources for individuals

Would you be interested in joining a parent committee? If so, please indicate which programs
DocuSign Waiver: MUST COMPLETE WHEN SUBMITTING THIS FORM. MAKE SURE TO SUBMIT 24-25 REGISTRATION BY CLICKING SUBMIT BELOW.
CLICK HERE TO COMPLETE DOCUSIGN.
I permit my childs photos without any identifying information to be used for publicity purposes by the Friendship Circle and its partners as it relates to Friendship Circle activities. We truly appreciate your willingness to let us show the community what our programs are all about. By allowing us to showcase your childs talents, you are enabling our organization to keep our costs low and marketing organic.

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.

Full Name
Program Payment: If you know the programs you would like to sign up for, please proceed to payment. If you are applying for scholarship or a 1st time participant, please select the programs interested in and leave payment section blank. We will discuss payment in the intake meeting. Scholarship will be emailed invoice.