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Walk4Friendship

Friendship House Registration – New Participants

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In addition to registering, new participants will have an intake meeting to get to know you better and provide the most rewarding experience your child can have from Friendship House.

For any questions please email info@bocafriendship.com or call 561-576-1650

1Participant Information

2Parent/Guardian Information

3Program Registration

4Medical & Emergency Information

5Waivers & Permission

Your Name *

First

Last

Your Email *

Participants Name *

First

Last

Gender *

Male
Female

Date of Birth *//

Where does participant attend school or work? *

If your child doesn't attend school or work, please explain?

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Additional Information:

What are your child's special needs? *

What languages does your child speak? *

How does your child best communicate? *

Verbal
Non-Verbal
Sign
Other

Which activities does your child enjoy doing most? *

Which activities does your child not like doing? *

Are there any activity restrictions for your child? *

Does your child occasionally exhibit any of the following behaviors?

Biting
Grabbing
Kicking
Cursing
Hitting
Pulling Hair
Other

Please Explain *

What is the best method of handling the situation?

Is your child completely toilet trained? *

Yes
No

Is your child sensitive to any of the following? *

Light
Noise
Touch
Movement
N/A

Please Explain *

Please list any therapists that your child is currently seeing: *

Is there anything else we should know about your child? (attention span, outgoing/shy, etc.)

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Mother's Name *

First

Last

Mother's Cell Phone Number *

Mother's Email *

Occupation

Father's Name

First

Last

Father's Cell Phone Number

Father's Email

Occupation

Marital Status? *

Please Explain.

Other Address

Address Line 1

Address Line 2

City

State

Zip Code

What is your religion? *

Which Temple are you affiliated with? *

Communication

Program updates will be sent out via text and email before the events. You can also follow us on Facebook and Instagram @bocafriendship to see our most up-to-date posts.

Text preference *

Mom
Dad
Both

I’d love to contribute with: (List any talents/ methods you can help)

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Programs

Friends@Home. Ages 4-17

Once a week throughout the school year, Friends@Home accommodates a wide variety of schedules. Friends@Home pairs teenage volunteers and children with special needs for hours of fun and friendship through weekly home visits. This provides children the chance to bond with their volunteers in an environment they are most comfortable in, while their parents and siblings receive much-needed respite. Through the weekly visits, the pair establish a warm friendship that combats the loneliness and isolation so often felt by individuals with special needs. At the same time, their teen volunteers learn the priceless value of giving.

I would like my child to be a part of Friends@Home. *

Yes
No

Background Check

Our insurance requires that anyone who interacts with minors needs to be screened. That said, both parents and adults in the house, while a Friendship House visit is taking place, need to complete a background check. We have partnered with Sterling Volunteers to complete this process securely. The Friendship House will never see your personal information or background information and will only receive a report verifying your ability to care for minors. If you sign up for our Friends@Home program, In your welcome email, you will be provided with our unique Friendship House code to use when entering your information

Please provide your first choice of time for the Friends@Home visit. *

*

Select the beginning of the hour. Friends@Home is a one-hour program.

Please provide your second choice of time for the Friends@Home visit. *

Select the beginning of the hour. Friends@Home is a one-hour program.

Sunday Circle. Ages 5 +

Sunday Circle offers a wonderful opportunity for children to gain from group activities while still receiving one-on-one attention from their volunteers. Activities include sports instruction, music and movement instruction, arts and crafts. Sunday Circle is a two-hour drop off program, creating an excellent respite opportunity for parents. Sunday Circle occurs up to twice a month from 2:00 - 4:00 pm from October through May. Volunteers will be paired up with their special friend

I would like my child to be a part of Sunday Circle. *

Yes
No

Young Adults Club. Age 18 +

Young adults with special needs enjoy a monthly program (Tuesdays 6:00 - 7:30) aimed at facilitating socialization with peers and young adult volunteers. The goal of this program is to give young adults with special needs the opportunity to make friends and hang out outside of the home in a fun, safe, and relaxed environment. We have organized activities for everyone to participate in that will help build confidence, social skills, and life skills… all while building memories and fostering friendships that will last years!

I would like my child to be a part of Young Adults Club *

Yes
No

NEW: Sports Circle Ages 9 - 15

Sports Circle is a weekly program from November through March on Wednesday afternoons where your child will learn essential team building, gross motor skills, and much more in a safe and fun environment. Your child will be paired with one on one volunteers who will be there to assist them and be their friend.

I would like my child to be a part of Sports Circle *

Yes
No

SAVE THE DATE! Walk4Friendship - Sunday, February 5, 2023

We are planning our first annual fundraiser to help raise crucial funds needed to continue our programming! If you can actively get involved, create a fundraising team, plan, etc., please contact Rabbi Sholom Kessler.

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Emergency Contact *

First

Last

*In case of emergency, when neither parent/guardian can be reached, please provide the name of a person who will assume responsibility for participant.

Relation to Participant? *

Emergency Contact Phone *

Emergency Care *

In case of emergency requiring emegency care, I authorize the paramedics to take Participant to the nearest hospital, if necessary.

Physician Name *

First

Last

Physician Phone *

Health Insurance Provider: *

Health Insurance ID Number *

Consent: *

I give Friendship House of Boca Raton permission to contact my child's doctor if emergency medical advice is needed and I can't be reached

Additional Medical Information *

Any additional medical information that would be helpful for us to know in case of emergency

Allergies & Dietary Restrictions: *

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For your convenience our Waivers & Permissions are now fully online.

Friendship House of Boca Raton Parent Waiver

It is our pleasure to provide our families with as much support and service as possible. It is necessary, however, for the parents of our participants to assume responsibility for any risk associated with activities and time their child shares with his/her volunteers and/or at any Friendship House program or activity, whether it be in your home, Chabad, Friendship House or elsewhere. This also includes the time when volunteers are driving the participant in their vehicles, or when one’s child is taking part in an activity that may include physical movement.

1. *

In exchange for the Friendship House Corp. (referred to in this document as “Friendship House” or "FH”) permitting my child or family member to participate in any Friendship House program or activity (which provides a benefit to my child, myself, and my family). I, individually, and on behalf of my spouse and family, assigns, and personal representatives, in our personal and representative capacities (hereinafter “Releasers), hereby assume all risk of harm and hereby release, acquit, and forever discharge the Friendship House and their employees, volunteers, officers, directors, parent organizations, subsidiaries, affiliates, trustees, insurers, and representatives - (in their representative and individual capacities-) (hereinafter “FH Releasees”) from any and all liability or claim whatsoever for any and all damages, losses, or injuries, including death, to persons or property or both, including but not limited to any claims, demands, actions, causes of action, damages, costs, expenses and attorneys' fees, which arise out of, during, or in connection with my participation, my families participation, and or our child's participation in any and all Friendship House programs and activities, including but not limited to any damages, losses, or injuries to persons or property or both which may be sustained or suffered by me or any person in connection with my ortheir association with, participation in, or travel to and from, and in conjunction with, any and all Friendship House programs and activities.

2. *

I agree not to hold the FH Releasees liable for any accident, loss or theft that may occur while my child is under their care. I hereby give my permission to the physician selected by the Friendship House to hospitalize, and/or secure necessary medical or other treatment or anesthesia for my child, (or any other family members who participate in any Friendship House program or activity) in the event that I cannot be reached in an emergency. I hereby give my permission for paramedics to transport my child or family member to the nearest hospital, if necessary. I have indicated any pertinent medical information on the Forms.

3. *

Releasers expressly agree to indemnify, defend, and hold harmless the FH Releasees (in their individual and official capacities) from any and all liability, loss or damages they or any of Releasers incur or sustain as a result of any claims, demands, damages, actions, causes of action, judgments, costs or expenses including attorneys' fees, which result from, arise out of, or relate to Releasers’ participation in, travel to and from, and/or in conjunction with any Friendship House program or activity.

4. *

Releasers agree that this Waiver, Release, and Indemnification Agreement is intended to be as broad and inclusive as permitted by the laws of the State of Florida, and if any portion hereof is held invalid, it is agreed that the balance hereof shall, notwithstanding, continue in full legal force in effect. To the extent necessary,

The safety of program participants, as well as Friendship House staff and volunteers, is paramount. Therefore, in addition to undergoing a background check, the parents and/or guardians of any child participating in Friendship House activities must affirm the following, by checking the accompanying box:

5. *

I agree to all of the above and allow my child to ride with any staff members or volunteers and I release them,the Friendship House of Boca Raton Corp., and the FH Releases referenced above of all responsibility and I, on behalf of myself and the Releasers above, assume all risk associated with any Friendship House staff, program or activity.

6. *

I hereby give permission for my child's photo to be displayed on any online websites or networks.

please note Friendship House will not use names or tags unless we reach out to you first.

Criminal History

7. *

No parent, legal guardian, siblings or others family members who will be present with the child participant at any Friendship House event, including the Friends@Home Program, have previously been convicted of, charged with, arrested for, or accused of sexual abuse of a child or young person, or any act of sexual misconduct, or of any crime of violence or involving the improper touching of another. Neither has any such person ever appeared on the Sex Offender Registry in any Country.

8. *

I acknowledge that all information shared about any or all members of my family is confidential. I also acknowledge however, that it may be necessary for such information to be shared by Friendship House, as needed, with or by caregivers, staff, volunteers or other affiliates of the Friendship House. On behalf of myself and the Releasers above, and in exchange for allowing my child or family member to participate in any Friendship House program or activity; I agree to allow the Friendship House to discuss any information (including health or personal information) that is pertinent to my child/family member, and/or to their participation in any Friendship House programs or activity, with any or all relevant staff members, volunteers, or other affiliates of the Friendship House in order for Friendship House to offer optimal services to my family member.

We encourage direct communication with the Directors of the Friendship House regarding any and all safety matters or other matters which affected your or your child and their participation in any Friendship House program or any activity. Sholom Kessler can be reached directly at (561) 788-4388. All matters brought to the Directors’ attention will be investigated and addressed, and, to the extent reasonable or necessary in the context of any investigation, in as discreet a manner as is reasonable under the circumstances.

MEDICAL WAIVER

1. *

My son/daughter has my permission to take part in Friendship House programs. I agree not to hold the Friendship House Releasees liable for any accident, loss or theft that may occur while my child is under their care. I hereby give my permission to the physician selected by the Friendship House to hospitalize, and/or secure necessary treatment or anesthesia for my child, as named above, in the event that I cannot be reached in an emergency. I hereby give my permission that paramedics can transport my child to the nearest hospital, if necessary. I have indicated any pertinent medical information above. I agree to the terms and conditions of this application. Additionally, I am checking the box to all that I am agreeing to by my signature below.

2. *

I hereby give my child permission to participate in all activities planned by Friendship House

3. *

In addition to the emergency-related instructions above, I hereby give permission to FH staffor volunteers to administer medications to my child, upon my request as per written instructions (non-emergency).

4. *

I understand and agree that any reference to the term "I" or "my" in this document shall meanI or me, on behalf of myself and all other Releasers, on whose behalf I am signing or initialing this document.

Parent's Name *

First

Last

Friendship House Participant’s Name *

First

Last

Signature *

Date / Time *

Name

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Email *

Friendship House

17950 N Military Trail

Boca Raton FL 33496

(561) 576-1650

An affiliate of Chabad of Boca Raton

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