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24-25 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 Name
Are you a new or returning partcipant?
Click or drag files to this area to upload. You can upload up to 5 files.
Click or drag files to this area to upload. You can upload up to 5 files.
Primary Guardian
Primary address (Child's residence)
Secondary Guardian
Authorized Person to pick up 1
Authorized Person to pick up 2

Medical/Behavioral Information

Medical/Health Related Conditions Please select all that apply
Is your child potty trained?
Please specify any behaviors your child may exhibit or any new behaviors that may be occuring.
Does your child receive behavioral therapy?
Will your child be attending programs with their own RBT/AID?

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?

Program Selection

What programs would you like to sign up for?
Annual Membership (Includes all programs September - May and No School Fun Days)
Does not include Winter/Spring/Summer Camps, or Summer Programs)
Sunday Circle (17 Sundays)
2 Sundays a month 10am -12pm. September - May. Ages 5-17. @Miami Learning Experience
Movement Mondays
Mondays 5-6 pm September- May Ages 5-17
Art Circle
Mondays 4-5 pm September- May Ages 5-17
Swimming Circle
Tuesday 400-500 pm. Session1 September - December. Session 2 March - May. Location: Miami Dade College Kendall Campus. Ages 5-17. MUST HAVE SOME SWIMMING EXPERIENCE.
Karate Circle
Tuesday 5- 6 pm Session1 September - December Session 2 January- May Ages 5-17
FC Band
Wednesday 4-5 pm Session1: September - December Session 2: January- May Ages 10-17
Drama Circle
Wednesday 5 - 6 pm Session2 January - May Ages 10-17
Music Circle
Thursday 400- 500 pm Session 2 January- May Ages 5-9
Life Skills Around Town
Thursday 400- 600 pm Session 2 January- May Ages 11-17

Kulanu Circle: Inclusion Hebrew School: Every Sunday: September - June: 930am -12pm Kulanu Circle Registration

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

Waivers

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

Program Payment: We have rolling admission and prorate the programs, if joining after programs start, leave payment blank and we will send an invoice via email.

Parent's Name