Adult

Adult 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

First

Last

Participant's Birth Date

Participant's Age (This form is for ages 18+ ONLY)

Participant's school

Participant's preferred language

Participant's race

Please upload a complete a photo of the participant.

Click or drag a file to this area to upload.

Please upload a complete copy of the most recent IEP or 504 plan (if applicable):

Click or drag a file to this area to upload.

Parent's/Guardian Name

First

Last

Parent's/Guardian relationship to participant

Parent's/Guardian occupation

Parent/Guardian Email

Parent/ Guardian Cell Phone

Parent/ Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent's/Guardian Name 2

First

Last

Parent's/Guardian 2 relationship to Participant

Parent's/Guardian 2 occupation

Parent's/Guardian 2 Email

Parent's/Guardian 2 Phone

Who does the participant live with?

Is this their first year participating in our program?

Yes
No

Have they participated in at least one program in the last year?

Yes
No

Are they toilet trained?

Yes
Mostly, but needs reminders
No

Medical/Health Related Conditions Please select all that apply

Other, please specify

Please provide more information and list all medications

Do they have any allergies or food sensitives? If so, please provide details.

What do they enjoy doing the most? Please list preferred activities, interests or hobbies

What makes them upset? Please list what might trigger frustration or challenging behaviors.

Is there anythign we should know? Please keep in mind our field trips can be in loud, crowded areas.

Please specify any behaviors your child may exhibit or any new behaviors that may be occuring

Please provide as much information as possible, as this is the information we provide to program Program Staff and therapists to help decrease these behaviors. Please share any calming or de-escalation strategies that may help

Do they receive behavioral therapy?

Yes
No

If yes, may we contact their therapist if needed? Please provide their name and phone number

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.

Yes
No

Which program are you interested in?

How did you hear about us?

CLICK HERE: Waiver for Young Adult Participant. MUST complete.

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.

(If you would like to apply for a scholarship, please select your median household income range)

Do you need Scholarship assistance?

Yes

Dropdown

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

First

Last

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Adult Registration Form (Ages 18+)

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