Children24 - Friendship Circle Miami

24-25 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

Are you a new or returning partcipant?

New (1st year)
Returning

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

Yes
No

Important notice: Since you are a 1st time participant, PRIOR to joining programs, we MUST first meet with you AND your child to get to know you both better and go over all the programs we have to offer. We will contact you to set up this meeting.

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?

Authorized Person to pick up 1

First

Last

Authorized Person to pick up 2

First

Last

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.

Will your child be attending programs with their own RBT/AID?

Yes
No

Important notice: Since you selected yes, they will be attending with their aid, we need their background check on file and a contract will be sent to sign by you and the aid.

How did you hear about Friendship Circle?

Scholarships

Scholarships are available. If you would like to apply for a scholarship, please indicate so below. Please select all programs you're interested in. We will review your form and send an invoice via email..

Do you need to apply for scholarship assistance for 24-25 year?

Yes
No

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

$35,000 or less
$36,000 - $55,000
$56,000 - $75,000
$76,000 - $115,000

Which programs would you like to sign up for?

Annual Membership (Includes all programs September - May and No School Fun Days)

Annual Membership - $1,500.00

Does not include Winter/Spring/Summer Camps, or Summer Programs)

Select programs:

Sunday Circle (16 Sundays)

Full Year - $300.00

2 Sundays a month 10am -12pm. September - May. Ages 5-17. @Miami Learning Experience

Movement Mondays

Full Year (28 classes) - $310.00
Session 1: September - December (12 classes) - $150.00
Session 2: January - May (16 classes) - $200.00

Mondays 5-6 pm September- May Ages 5-17

Art Circle

Full Year (28 classes) - $310.00
Session 1: September - December 9 (12 classes) - $150.00
Session 2: January- May (16 classes0 - $200.00

Mondays 4-5 pm September- May Ages 5-17

Swimming Circle

Full Year (20 classes) - $200.00
Session 1: September - December (13 classes) - $160.00
Session 2: March- May (7 classes) - $85.00

Tuesday 400-500 pm. Session1 September - December. Session 2 March - May. Location: Miami Dade College Kendall Campus. Ages 5-17. MUST HAVE SOME SWIMMING EXPERIENCE.

Karate Circle

Full Year: (31 classes) - $320.00
Session 1: September - December (12 classes) - $150.00
Session 2: January - May (19 classes) - $210.00

Tuesday 5- 6 pm Session1 September - December Session 2 January- May Ages 5-17

FC Band

Full Year: (31 classes) - $0.00
Session 1: September - December (12 classes) - $0.00
Session 2: January- May (19 classes) - $0.00

Wednesday 4-5 pm Session1: September - December Session 2: January- May Ages 10-17

Drama Circle

Session 1: September - December (11 classes) - $150.00

Wednesday 5 - 6 pm Session1 September - December Ages 10-17

Music Circle

Full Year (28 classes) - $320.00
Session 1: September - December (10 classes) - $110.00
Session 2: January- May (19 classes) - $235.00

Thursday 400- 500 pm Session1 September - December Session 2 January- May Ages 5-9

Life Skills Around Town

Full Year: (28 classes) - $500.00
Session 1: September - December (10 classes) - $180.00
Session 2: January- May (19 classes) - $380.00

Thursday 400- 600 pm Session1 September - December Session 2 January- May Ages 11-17

Kulanu Circle: Inclusion Hebrew School: Every Sunday: September - June: 930am -12pm Kulanu Circle Registration

I am also interested in the following programs:

Project Lifeline
Parent Support/ Wellness Groups

* Project Lifeline: Assisting families with community resources for individuals *

Would you be interested in joining a parent committee? If so, please indicate which programs

DocuSign Waiver: MUST COMPLETE WHEN SUBMITTING THIS FORM. MAKE SURE TO SUBMIT 24-25 REGISTRATION BY CLICKING SUBMIT BELOW.

CLICK HERE TO COMPLETE DOCUSIGN.

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

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

Program Payment: If you know the programs you would like to sign up for, please proceed to payment. If you are applying for scholarship or a 1st time participant, please select the programs interested in and leave payment section blank. We will discuss payment in the intake meeting. Scholarship will be emailed invoice.

Total

Item Quantity Total

There are no products selected.

Annual Membership (Includes all programs September - May and No School Fun Days) - Annual Membership 1 $1,500.00

Sunday Circle (16 Sundays) - Full Year 1 $300.00

Movement Mondays - Full Year (28 classes) 1 $310.00

Movement Mondays - Session 1: September - December (12 classes) 1 $150.00

Movement Mondays - Session 2: January - May (16 classes) 1 $200.00

Art Circle - Full Year (28 classes) 1 $310.00

Art Circle - Session 1: September - December 9 (12 classes) 1 $150.00

Art Circle - Session 2: January- May (16 classes0 1 $200.00

Swimming Circle - Full Year (20 classes) 1 $200.00

Swimming Circle - Session 1: September - December (13 classes) 1 $160.00

Swimming Circle - Session 2: March- May (7 classes) 1 $85.00

Karate Circle - Full Year: (31 classes) 1 $320.00

Karate Circle - Session 1: September - December (12 classes) 1 $150.00

Karate Circle - Session 2: January - May (19 classes) 1 $210.00

FC Band - Full Year: (31 classes) 1 $0.00

FC Band - Session 1: September - December (12 classes) 1 $0.00

FC Band - Session 2: January- May (19 classes) 1 $0.00

Drama Circle - Session 1: September - December (11 classes) 1 $150.00

Music Circle - Full Year (28 classes) 1 $320.00

Music Circle - Session 1: September - December (10 classes) 1 $110.00

Music Circle - Session 2: January- May (19 classes) 1 $235.00

Life Skills Around Town - Full Year: (28 classes) 1 $500.00

Life Skills Around Town - Session 1: September - December (10 classes) 1 $180.00

Life Skills Around Town - Session 2: January- May (19 classes) 1 $380.00

Subtotal

Total $0.00

Stripe Credit Card

24-25 Child Registration Form (Ages 5-17)

Important notice: Since you are a 1st time participant, PRIOR to joining programs, we MUST first meet with you AND your child to get to know you both better and go over all the programs we have to offer. We will contact you to set up this meeting.

Important notice: Since you selected yes, they will be attending with their aid, we need their background check on file and a contract will be sent to sign by you and the aid.

Scholarships

Which programs would you like to sign up for?

DocuSign Waiver: MUST COMPLETE WHEN SUBMITTING THIS FORM. MAKE SURE TO SUBMIT 24-25 REGISTRATION BY CLICKING SUBMIT BELOW.

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