1Applicant2Medical Info3All About Me4Parents5Consent HiddenSubmission ID HiddenDebug Registration is for* Participant Sibling Participant's InfoParticipant's Name* First Last Gender* Male Female Birth Date*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*HiddenGrade 2019/20* HiddenTemple Affiliation* While most of our programs are non-sectarian and open to the entire community, we do offer some Jewish religious programs for the Jewish community. Association:* YES, I am Jewish and want to be updated with the Jewish programs. NO, I am not and would like to be updated with the non-sectarian programs. Note: Participant Photo*Accepted file types: jpg, gif, png, jpeg, Max. file size: 50 MB.Important InfoThe participant requires Teen volunteer Trained adult aide – There will be an additional cost for the aide per program I will supply my own aide – no additional cost Does the participant occasionally exhibit any of the following behaviors? Biting Grabbing Kicking Cursing Hitting Running Other Other behavior* What is your best method of handling the situation?*Other things you would like to tell us about the participant AllergiesDoes applicant have any allergies?* Yes No Applicant is allergic to Hay Fever Poison Ivy/Oak 3. Insect Stings Food Penicillin Other Drugs Other Food Allergies* Drug Allergies* Other Allergies* HiddenNumber of Allergies CheckedDescribe reaction and treatment*Does applicant require an EpiPen?* Yes No If applicant requires an EpiPen, please list all instructions*EpiPen Authorization* Should the applicant have an allergic reaction, I give permission for staff to administer the EpiPen. HiddenMedicationsHiddenWill the applicant be taking medications during any LifeTown program?* Yes No Please list all prescription and non‐prescription medications the applicant will need administered during programs. Include the medication name, prescribing physician, physicians’ phone number, and the dosage instructions. When you check‐in at programs, please provide all medications (in their original packaging that identifies the prescribing physician (if prescription drug), the name of the medication, the dosage, and frequency of administration.HiddenMedicationsConfiguration RequiredUse the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.HiddenMedication Authorization* I hereby authorize the staff to administer these medication(s) per physicians orders at LifeTown programs. Medical HistoryDoes the applicant have a history of or is prone to any of the following Recent injury, illness or infectious disease Chronic or recurring illness Asthma Frequent Ear Infections Seizure Disorder or Convulsions Heart Defect/Disease Hypertension Bleeding/Clotting Disorders Diabetes Joint problems (knees, ankles) Fractures Frequent Headaches Head Injury Eating Disorder Diarrhea or constipation Frequent Stomachaches Other Other* HiddenNumber of Medical History CheckedPlease provide explanation for any checked items*Physical Activities to be limited or restricted while at LifeTown ProgramsHiddenEmergency Contact Name (other than parent) First Last HiddenEmergency Cell All About Me!Important information that my volunteer needs to know.CommunicationCommunication* I am verbal I am not verbal What is the best way to communicate with me?FoodFood* I can eat independently I need assistance eating Are there any food limitations or a special diet?* Yes No Please specify*BehaviorI Like*I don't like*If I need to be redirected, this is what helps meBathroomBathroom* I can go independently I need assistance I am not toilet trained Please Describe* Parent/Guardian InfoResponsible Party* Mother Father Guardian Responsible Party's InfoMother's InfoFather's InfoGuardian's InfoName* First Last Occupation Cell Number*HiddenCell Carrier E-mail* Parent’s Status* Married Widowed Divorced Separated Would you like to receive emails from our LifeTown parent network?* Yes No Other Parent's InfoMother's InfoFather's InfoOther Guardian's InfoName* First Last Occupation* Cell Number*E-mail* SignatureWill you be sending a caregiver / aide / nurse?* Yes No HiddenCOVID procedures* I will stay home if myself or anyone in my household is not feeling well and if anyone has been exposed to or has COVID-19. I will inform Friendship Circle if I tests positive for COVID-19. According to the CDC guidelines, individuals who are fully vaccinated do not need to wear masks. Individuals who are not vaccinated including children 2 years and older should wear a mask covering their mouth and nose when in public. I have reviewed and agree to the following procedures: (Please check each item to confirm you have reviewed it. You must check all boxes)Code of Conduct Parent/Guardian Signature Actions Edit Delete There are no Code of Conducts. Add Code of Conduct Maximum number of code of conducts reached. Please read and sign the code of conductI allow applicant's photo to be used for any and all LifeTown publicity purposes.* Yes No Who is filling out this form?* Mother Father Legal Guardian * I hereby give permission to the Friendship Circle-LifeTown administration to take whatever medical measures they deem necessary for my child in the event of a medical emergency. Signature*CommentsNameThis field is for validation purposes and should be left unchanged.
