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23-24 Adult Registration Form (Ages 18+)

  • 23-24 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).
  • Emergency Contact

    In case of emergency, when parents/guardians cannot be reached, please provide the contact information of someone who will take responsibility of your child. (Not the parents/guardians listed)
  • Please indicate what programs they 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.
  • 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.

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