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Summer Youth Programs

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)

Are you currently registered for the 2025-2026 year with Friendship Circle?

Primary Email Address

Primary Phone Number

Authorized Person #1 (Pick-up and Drop-off)

First

Last

Authorized Person #1 Phone Number

Authorized Person #2 (Pick-up and Drop-off)

First

Last

Authorized Person #2 Phone Number

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

Does your child carry emergency medicine on them and will be bringing to programs? (Ex: Epi-pen or Seizure Spray)

If you child carries an EPI- PEN you MUST carry Benadryl to administer as well. Friendship Circle Miami WILL ONLY administer NASAL SEIZURE SPRAY AND EPI-PEN, we WILL NOT administer daily medications, NSAIDS or rectal seizure spray. In the event of a seizure or epi-pen is required 911 will be called as well as Primary Contact.

Will your child be attending programs with their own Registered Behavior Technician (RBT)?

Scholarships

Did you apply for Scholarship assistance (2025/26)

Friendship Circle Program(s):

Please let us know which programs you’d like to register for...

Art Circle: (Mondays 4:00-5:00PM)

July 6 - July 27 - $60.00

Unleash your creativity on Mondays from 4:00PM – 5:00PM in our interactive Art Circle.

Movement Circle: (Mondays 5:00-6:00PM)

July 6 - July 27 - $60.00

Join us every Monday from 5:00PM – 6:00PM for an engaging and energetic movement session.

FC Band Circle: (Wednesday from 4:00PM - 5:00PM: Free

July 8 - July 29

No musical experience is needed.

Karate Circle: (Wednesday from 5:00 -6:00 pm)

July 8 - July 29 - $60.00

Get active and develop teamwork every Wednesday from 5:00PM – 6:00PM in Karate Circle with Kia Kidz, where all skill levels are welcome.

Cooking Circle: (Thursdays from 4:00 -5:00 pm)

July 9 - July 30 - $80.00

Participation in our cooking class is not encouraged for individuals with food allergies, including but not limited to wheat and nuts. Ingredients are used throughout the facility, and cross-contamination cannot be guaranteed.

I hereby grant permission for photographs of my child, without any identifying information, to be used by Friendship Circle and its partners for publicity related to Friendship Circle activities.

We sincerely appreciate your support in helping us share the impact of our programs with the community. By allowing us to highlight your child’s talents, you contribute to keeping our costs low and our marketing efforts authentic and effective.

Program Payment

Please DO NOT use Secure, fast checkout with Link and proceed to enter card payment information.

Parent's Name

First

Last

Total

Item Quantity Qty Total

There are no products selected.

Art Circle: (Mondays 4:00-5:00PM) - July 6 - July 27 1 $60.00

Movement Circle: (Mondays 5:00-6:00PM) - July 6 - July 27 1 $60.00

FC Band Circle: (Wednesday from 4:00PM - 5:00PM: Free - July 8 - July 29 1 $0.00

Karate Circle: (Wednesday from 5:00 -6:00 pm) - July 8 - July 29 1 $60.00

Cooking Circle: (Thursdays from 4:00 -5:00 pm) - July 9 - July 30 1 $80.00

Subtotal

Total $0.00

Enter Payment Information

Please DO NOT use Secure, fast checkout with Link and proceed to enter card payment information.

Scholarships

Friendship Circle Program(s):

Program Payment

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