Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Birth Date *

MM

DD

YYYY

Session *

November 2019

February 2020

Mother's Name *

First Name

Last Name

Mother's Cell *

(###)

###

####

Father's Name *

First Name

Last Name

Father's Cell *

(###)

###

####

Marital Status

Married

Divorced

*

I hereby give my son/daughter permission to participate in Friendship Circle programs.

I permit my son/daughter's photo to be used for publicity purposes.

I hereby release the Friendship Circle, its providers and administrators, from ALL liability for any incident which affects the health, welfare, or safety of my child in the provision of a Friendship Circle program for the year 2018-19