Family Registration – Friendship Circle Toronto

Child's Name*

First Last

Gender*

Male
Female

Age*

Please enter a number less than or equal to 100.

Date of Birth*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent's Information

Mother's Full Name

First Last

Fathers's Full Name

First Last

Mother's Email

Mother's Cell Phone

Father's Email

Fathers's Cell Phone

Home Phone

School

Parental Status

Married
Divorced

If divorced child lives with

Synagogue Affiliation

About your child

Does your child occasionally exibit any of these behaviors:

biting
kicking
hitting
pulling hair
grabbing

What is the best method to handle the situation

Other things you would like to tell us about your child

Medical/ Diagnosis/ Concerns:

Please list any allergies

Emergency contact name

First Last

Emergency contact phone number

Siblings

Name	Age

I permit my child's photos to be used for Friendship Circle publicity purposes

yes
no

What are your expectations of Friendship Circle?

What are some of the changes you hope to see in your child?

Are there any special activities that should be worked on or introduced?

Are there any concerns regarding the adaptive level of your child while interacting with new persons or in new situations?

Program Selection

You can check off which programs you're interested in and would like to here more about.

Friends @ Home (Volunteer must consent to being alone with your child at home, if you won't be home.) Free of charge.

yes
no

Sunday Circle: $395 10:45-12:45 pm

yes
no

Subsidies Available email friendshipcircle@chabad.ca Dates: September 29- pre-holiday sunday circle nOVEMBER 3, 10, 17, 24 DECEMBER 8, 15 JANUARY 12, 19, 26 FEBURUARY 2, 9, 16 MARCH 2, 16, 23, 30 APRIL 6, 27 MAY 4, 11

Birthday Club When is your child's birthday?

Mom's Club. Free of charge.

yes
no

Family Holiday Programs, Dates coming.

yes
no

Holiday Cooking Club: Age: 8+

yes
no

Payment

Sunday Circle

Price:

Total

$ 0.00 CAD

Payment method

Pay online now by Credit Card
Cheque / Requesting Subsidy

Credit Card

American Express

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Where did you hear about Friendship Circle?

Email address for CC receipt

CAPTCHA