Child Select A Child to edit or Add New Child Name Prefix - None -Mrs.Ms.Mr.Dr.RabbiThe HonorableMiss First Name * Last Name * Gender - None -FemaleMale Birth Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Birth Date Before Sunset Yes No ABOUT YOUR CHILD Give a brief description of your child What would you most like your child to gain by participating in Friendship Circle activities? Does your child exhibit any of the following behaviors? Pulling Hair Cursing Grabbing Kicking Hitting Biting None of the Above Other Please describe What is your best method of handling the situation? Describe your child's communication skills Child's favorite activities Child's least favorite activities SCHOOL INFO School Name School Phone Number MEDICAL INFO Medical Concerns/Diagnosis Does your child take medication regularly? Yes No Please list medications taken regularly Any activities that your child should not be participating in due to a limitation or medical condition Date of last tetanus shot Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075 Does your child have any medical or environmental/pet allergies? Yes No Please list allergies Dietary Restrictions Vegan Lactose Intolerant None Other Please list other dietary restrictions INSURANCE / HEALTH PROVIDER Medical Insurance Carrier Policy Number Doctor's First Name Doctor's Last Name Doctor's Office Phone Number Hospital Affiliation Submit
