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 Year19261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 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 Year19911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040204120422043204420452046204720482049205020512052205320542055205620572058205920602061206220632064206520662067206820692070207120722073207420752076 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
