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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
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
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?
Which program are you interested in?
Has your child attended at least one program within the past year?
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.
Scholarships

Scholarships and payment plans are available. If you would like to apply for a scholarship or payment plan, please indicate so below. Please select all programs you're interested in. We will receive your form and reach out to set up the details.

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