Children and Teens

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

First

Last

Child's Birth Date

Age (This form is for ages 5-17 ONLY)

Child School

Child's Grade

Please upload a complete copy of your child's most recent IEP or 504 plan:

Click or drag files to this area to upload. You can upload up to 5 files.

Photo of your child

Click or drag files to this area to upload. You can upload up to 5 files.

Child's preferred language

Child's race

Child's ethnicity

Primary Guardian

First

Last

Relationship to child

Occupation

Primary Email

Primary cell phone

Primary address (Child's residence)

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Guardian

First

Last

Secondary relationship to child

Secondary Occupation

Secondary Email

Secondary Cell Phone

Who does the child live with?

Medical/Health Related Conditions Please select all that apply

Other please specify

Does your child have any allergies or food sensitivities? If so, please provide details.

Is your child potty trained?

Yes!
Mostly, but they need reminders.
No, they wear diapers.

What does your child enjoy doing the most? Please list preferred activities, interests or hobbies.

What makes your child upset? 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.

Physical Agression (hitting, biting, hair pulling, kicking, etc)
Verbal Aggression/Cursing
Repetive Stimming (hand flapping, pacing, repeating words or phrases, rocking body, etc)
Elopement/Running Away
Self- Injurious Behavior
Property Destruction
Tantrum
Other (please specify)
None

Other please specify

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

Does your child receive behavioral therapy?

Yes
No

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

Which program are you interested in?

How did you hear about us?

Has your child attended at least one program within the past year?

Yes
No

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

DocuSign Waiver. CLICK HERE MUST COMPLETE BEFORE SUBMITTING.

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.

Do you need Scholarship assistance?

Yes

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

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

Layout

Child Registration Form (Ages 5-17)

Scholarships

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