23-24 Child Registration Form (Ages 5-18)

23-24 Participant Registration Form (Ages 5-18)
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).
Child's Name*

First Name Last Name
Birth Date*

Month Day Year
Age (This form is for ages 5-18 ONLY)*
Child's Grade*
Child's School*
Please upload a complete copy of your child's most recent IEP or 504 plan:*
Child's preferred language*
Child's Race*
Other
Child's Ethnicity*
Please upload a recent photo of your child:*
Primary Guardian*

First Name Last Name
Relationship to child*
Birth Date*

Month Day Year
Occupation
Primary E-mail*
Primary Cell Phone*

Primary Address (Child's Residence)*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Secondary Guardian

First Name Last Name
Relationship to child
Birth Date

Month Day Year
Occupation
Secondary E-mail
Secondary Cell Phone
Who does the child live with?*
Is this your child's first year participating in our program?*
How did you hear about our program?*
Medical/Health Related Conditions Please select all that apply*

Autism Spectrum DisorderLearning DisabilityVisual Impairment or BlindSeizuresDown SyndromeIntellectual DisabilityDevelopmental DisabilityCerebral PalsySpeech or Language ConditionAsthmaFragile X SyndromeHearing Impairment or DeafUses assistive device(s) like a wheelchair, brace or walkerOther (Please specify)
Please provide more information*
Does your child have any allergies or food sensitivities? If so, please provide details.*
Is your child toilet trained?*

YesMostly, but they need remindersNo, 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 Aggression (Hitting, biting, hair pulling, kicking, etc.)Elopment / Running AwaySelf-Injurious BehaviorVerbal Aggression / CursingProperty DestructionTantrumRepetitive Stimming (Hand flapping, pacing, repeating words or phrases, rocking the body, etc.)Other (Please specify)None of the above
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?*

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

In case of emergency, when parents cannot be reached, please provide the contact information of someone who will take responsibility of your child. (Not the parents/guardians listed)
Full Name*

First Name Last Name
Relationship to child*
Cell Phone Number*
Please indicate what programs your child would like to participate in.

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 and close out the tab when it asks for payment. We will receive your form and reach out to set up the details.
If you would like to apply for a scholarship, please select your median household income range.
FC Annual Membership (Includes ALL FC programs for the 23-24 program year (Excluding Camps, Kulanu Circle & Friends @ Home)

$1,500 (72% discount)
Sunday Circle's - Twice a month (15 Sundays from Oct. 2023 - May 2024) AGES 5-18

Full year - 15 classes $300
Art Circle - Mondays from 4-5pm (26 Mondays from Oct. 2023 - May 2024) AGES 10-18

Full year - 26 classes $310Session 1 - 14 classes (Oct. 23-Jan. 24) $175Session 2 - 12 classes (Feb. 24-May 24) $150
Movement/Zumba - Mondays from 5-6pm (26 Mondays from Oct. 2023 - May 2024) AGES 7-18

Full year - 26 classes $310Session 1 - 14 classes (Oct. 23-Jan. 24) $175Session 2 - 12 classes (Feb. 24-May 24) $150
Swimming Circle - Tuesdays from 4:30-5:30pm (18 Tuesdays from Oct. 23-Dec. 23 and Apr. 24-May 24) AGES 5-18

Full year - 18 classes $190Session 1 - 11 classes (Oct. 23-Dec. 23) $140Session 2 - 7 classes (Mar. 24-May 24) $85
Equestrian Circle - Tuesdays from 4-4:45pm or 4:45-5:30pm (11 Tuesdays from Jan. 24-Mar. 24) Certain restrictions apply. Group times are not guaranteed.

First group - 4:00-4:45pm - 11 classes $130Second group - 4:45-5:30pm - 11 classes $130
FC Band - Wednesdays from 4-5pm (27 Wednesdays from Oct. 23-May 24) If your child misses more than 5 classes, we reserve the right to give their spot to another child. AGES 10-18

Full year - 27 classes - Free of chargeSession 1 - 14 classes (Oct. 23-Jan. 24) Free of chargeSession 2 - 13 classes (Feb. 24-May 24) Free of charge
Drama Circle - Wednesdays from 5-6pm (27 Wednesdays from Oct. 23-May 24) AGES 10-18

Full year - 27 classes $320Session 1 - 14 classes (Oct. 23-Jan. 24) $175Session 2 - 13 classes (Feb. 24-May 24) $175
Music Circle - Thursdays from 4-5pm (28 Thursdays from Oct. 23-May 24) AGES 5-11 only

Full year - 28 classes $320Session 1 - 13 classes (Oct. 23-Jan. 24) $163Session 2 - 15 classes (Feb. 24-May 24) $188
Life Skills Around Town - Thursdays from 4-6pm (28 Thursdays from Oct. 23-May 24) AGES 12-18

Full year - 28 classes $520Session 1 - 13 classes (Oct. 23-Jan. 24) $260Session 2 - 15 classes (Feb. 24-May 24) $300
Kulanu Circle - Inclusion Hebrew School - Sundays from 9:30am-12pm from September 2023- June 2024

Please click here to receive the registration form, payment link and informative email. Tuition $750
Friends at Home - September 2023 - May 2024 Program pending volunteer registration. If possible, please choose two days of the week that would be best for home visits. AGES 5-18

MondayTuesdayWednesdayThursdaySunday
I am also interested in the following programs

No School Fun DaysWinter CampSummer CampAdult Programs (Ages 18 +)Project LifelineParent Support / Wellness Groups
Would you be interested in joining a parent committee? If so, please indicate which programs

Welcome Back CelebrationFamily Fun DaysMom's Night OutDad's Night OutWalking 4 FriendshipMorning of Talent
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.*

AgreeDisagree
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. For Friends @ Home Participants: By typing my name below, I agree that a parent or legal guardian will be at home at all times while volunteers are interacting with my child(ren). 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 Name Last Name
Total

$0.00

Payment

Credit Card Other payment

Postal / Zip Code

Country

Should be Empty:

This page uses TLS encryption to keep your data secure.

23-24 Participant Registration Form (Ages 5-18)

Emergency Contact

Please indicate what programs your child would like to participate in.