Registration -

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1Let's Get Started

2Getting to Know You

3Medical & Emergency Info

4Consent & Communication

Your Name *

First

Last

Your Email *

Participant Info

Name *

First

Last

Date of Birth *

Gender *

Male
Female

Let us know where the participant spends their day — school, work, or another setting. *

Mother's Info

First Name *

Last Name *

Phone Number *

Email *

Occupation

Father's Info

First Name *

Last Name *

Phone Number *

Email *

Occupation

Family Info

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status? *

What is your religion? *

Are you affiliated with any Temple? *

We primarily share updates via text. Who should receive text messages about your child’s programs? *

Mom
Dad
Both

Your Child’s Needs, Strengths & Preferences

We’d love to learn more about your child or young adult so we can offer a welcoming, supportive experience. These questions help us understand how to best connect, communicate, and include them in our programs. Just answer to the best of your ability, this helps us create a positive and meaningful experience together.

If your child or young adult has a formal diagnosis, please share it here. *

If you’re unsure of the wording or still in the process of evaluation, please explain here.

Does your child or young adult have any specific needs or challenges we should be aware of? *

What language(s) does your child or young adult speak or understand best? *

How does your child or young adult usually communicate? *

Verbal
Non-verbal
Sign language
Communication device

What types of activities does your child or young adult enjoy most? *

Are there any activities your child or young adult prefers to avoid? *

Are there any activities your child or young adult should avoid for medical, physical, or behavioral reasons? *

Does your child or young adult occasionally exhibit any of the following behaviors? (Select all that apply) *

Biting
Grabbing
Kicking
Cursing
Hitting
Pulling Hair
Other (please explain)
N/A

If you selected any of the above, can you briefly describe the situations in which these behaviors may occur?

What is the most effective way for us to respond or help if one of these behaviors occurs?

Is your child or young adult fully toilet trained? *

Is your child or young adult sensitive to any of the following? (Select all that apply) *

Light
Noise
Touch
Movement
N/A

If selected, can you share a little more about what sensitivity looks like for them?

Are there any therapists your child or young adult is currently working with? *

(You can list names, specialties, or simply the type of support they’re receiving — e.g., speech therapy, OT, etc.)

Is there anything else you’d like us to know about your child or young adult?

(For example: attention span, social preferences, personality traits, etc.)

Our Programs

Take a moment to explore the programs listed below. These are some of the ways your child or young adult can get involved, and we’ll go over everything in more detail together during the intake meeting.

Sunday Circle (Ages 5 + )

A Sunday drop-off program with fun group activities and one-on-one support.

Equine Connection

A monthly Sunday morning program where participants connect with horses through hands-on activities and meaningful experiences.

Young Adult Club (Age 18 +)

A evening hangout for young adults to connect, grow, and explore the community.

Sports Circle (Ages 8 +)

A weekly Wednesday program focused on team-building, movement, and fun physical activity.

Brighter Birthdays

Personalized birthday visits to make your child feel celebrated and included.

Family & Holiday Events

Seasonal gatherings that bring families together and build community.

Walk4Friendship

Our annual community walk celebrating inclusion and supporting Friendship House.

Tour de Friendship

A meaningful cycling event supporting children and young adults with special needs.

Helping Us Grow (Optional)

Friendship House is always growing with the help of families who care. There’s no pressure — but if you’d ever like to get involved or help us grow, we’d love to hear from you.

Is there a talent, skill, or way you’d like to contribute to Friendship House — whether by helping directly or spreading awareness?

If you have any thoughts, feedback, or ideas to share, we’d love to hear them:

(This helps us keep you in mind for future opportunities.)

Know Another Family Who Might Love Friendship House?

If you know another family who could benefit from the warmth and support of Friendship House, we’d be happy to reach out and welcome them.

Name

First

Last

Phone

Anything you’d like us to know?

Emergency Contact

This should be someone other than a parent in case they can’t be reached

Name *

First

Last

Relation to Participant? *

Phone Number *

Emergency Authorization

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

I Agree

Physician Info

Name *

First

Last

Phone *

Health Insurance

Insurance Provider: *

Insurance ID Number *

Medical 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 *

I Agree

Medical Notes

Additional Medical Info (Any condition we should know about) *

Allergies / Dietary Restrictions *

Permission & Waivers

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.

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.

Direct Communication

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.

Participant’s Name *

First

Last

Parent's Name *

First

Last

By typing my name above, I release Friendship House Corporation, its providers, and administrators from all liability for any incidence which affect the health, welfare, or safety of my child/self while participating in Friendship House Programs.

Date / Time *

Signature *

Clear Signature

Let's Stay in Touch

We’ll send important updates by text, so please make sure the number you gave is one you check regularly. You may also receive occasional updates by email. Save 561-788-4388 as “Friendship House” so you don’t miss a thing!

Help Us Continue Our Mission Ι Click Here

Making a difference in the lives of youth with special needs!

Welcome to Friendship House!

Where Every Child is Seen, Included, and Celebrated.

Already a participant? Click here

We’re so glad you’re here. Friendship House is a community where children and young adults with special needs are embraced, included, and supported through meaningful programs and friendships.

As a new participant, this form is the first step in joining our Friendship House family. After registering, we’ll reach out to schedule a short intake meeting to get to know you and ensure your child receives the most personalized and rewarding experience possible.

Have any questions? We’re here for you – just email us at info@bocafriendship.com or call 561-576-1650.

Participant Info

Mother's Info

Father's Info

Family Info

Your Child’s Needs, Strengths & Preferences

Our Programs

Sunday Circle (Ages 5 + )

Equine Connection

Young Adult Club (Age 18 +)

Sports Circle (Ages 8 +)

Brighter Birthdays

Family & Holiday Events

Walk4Friendship

Tour de Friendship

Helping Us Grow (Optional)

Know Another Family Who Might Love Friendship House?

Emergency Contact

Emergency Authorization

Physician Info

Health Insurance

Medical Consent

Medical Notes

Permission & Waivers

Friendship House of Boca Raton Parent Waiver

Criminal History

MEDICAL WAIVER

Direct Communication

Let's Stay in Touch

Friendship House

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