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ValleyFriendshipCircle.com » Programs » SYMPHONY CIRCLE!  » Symphony Circle Application  » Symphony Circle Application
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SYMPHONY CIRCLE APPLICATION

See Below for Dates & Fees

Partial & Full Scholarships Available!

Times: 10 am- 12 pm

Ages: 6-16

By checking this box I/We agree that my/our typed signatures be accepted as my/our written signatures.
CHILD INFORMATION
FIRST NAME: GENDER: MALE FEMALE
LAST NAME: HEBREW NAME:
DATE OF BIRTH: HEBREW B-DAY (IF KNOWN):
SCHOOL ATTENDING: GRADE ENTERING:
HOME ADDRESS OF CHILD:
HOME TELEPHONE:
PARENTS/GUARDIAN STATUS: MARRIED DIVORCED SEPARATED SINGLE PARENT
CHILD LIVES WITH:

What activities does your child enjoy?

Describe your child's Special Need?


Is there anything in particular that your child does not like doing?

Does your child exhibit any serious behavioral issues that we need to be aware of? If so, please describe.

Is there anything you would like us to know about your child?

Volunteers will be assisting your child. To what personality does your child respond best?

Have you been to a Valley Friendship Circle program? YES NO
How were you referred:


PARENTS/GUARDIAN INFORMATION

MOTHER FATHER
TITLE: TITLE:
SURNAME: SURNAME:
GIVEN NAME: GIVEN NAME:
HEBREW NAME: HEBREW NAME:
OCCUPATION: OCCUPATION:

HOME ADDRESS:

HOME ADDRESS:
HOME TELEPHONE: HOME TELEPHONE:
WORK TELEPHONE: WORK TELEPHONE:
EMAIL: EMAIL:
CELL PHONE: CELL PHONE:
PREFERRED METHOD OF CONTACT: PREFERRED METHOD OF CONTACT:
SYNAGOGUE AFFILIATION: SYNAGOGUE AFFILIATION:


GRANDPARENTS – SHARE THE NACHAS!
PATERNAL GRANDPARENTS MATERNAL GRANDPARENTS
NAMES: NAMES:
EMAIL: EMAIL:
PHONE: PHONE:
HOME ADDRESS: HOME ADDRESS:


SYMPHONY CIRCLE HEBREW SCHOOL

PLEASE CHECK OFF THE DATES THAT YOU WOULD LIKE YOUR CHILD TO JOIN SYMPHONY CIRCLE

Sept 20 | Oct 25 | Nov 8 | Dec 6 | Jan 10 | Feb 7 |

Mar 13 | Apr 3 | May 1 | Jun 19

MEDICAL INFORMATION
CHILD’S LEGAL NAME: DATE OF BIRTH:

ANY PRESENTING MEDICAL CONDITIONS OR ALLERGIES? YES NO

IF YES, DOES YOUR CHILD NEED ANY SPECIAL REMINDERS OR ASSISTANCE?

IS YOUR CHILD ON A RESTRICTIVE DIET? YES NO

IF YES, PLEASE EXPLAIN
EMERGENCY CONTACT: RELATIONSHIP TO CHILD:
EMERGENCY CONTACT: RELATIONSHIP TO CHILD:
HOME TELEPHONE: CELL PHONE:
DOCTOR: DOCTOR’S TELEPHONE:

ADDITIONAL MEDICAL INFORMATION OR COMMENTS:

INSURANCE
INSURANCE CARRIER:
PHONE NUMBER: POLICY NUMBER:


ACCIDENT AND TRIP DECLARATION
ACCIDENT: As the parent(s) / legal guardian of (child's name), I/we authorize any adult acting on behalf of friendship circle Los Angeles to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Valley Friendship Circle personnel will try, but are not required, to communicate with me prior to such treatment.
TRIPS AND OUTINGS: I hereby give permission for my child (child’s name) to attend and participate in all trips and outings organized as part of the program by the Valley Friendship Circle.
PARENT/GUARDIAN SIGNATURE (INITIAL) DATE
PARENT/GUARDIAN SIGNATURE (INITIAL) DATE

COMMITMENT TO EVERYONE'S
SAFETY AND WELL-BEING
Valley Friendship Circle provides very special and unique opportunities for volunteers, special friends and their families to enrich the lives of each other. In doing so, participants might encounter new and sometimes challenging situations. Thus, it is imperative to set expectations at the beginning so that volunteers, special friends, and parents understand what they can expect. Therefore, volunteers, special friends, and their families must each certify and agree by initialing each line and signing below that they:
Understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct;
Understand that participation in Valley Friendship Circle activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for me and/or my child to participate in this activity;
Acknowledge the risk of injury from the activities involved in the Valley Friendship Circle events or program and knowingly and freely assume all such risks;
Will not allow my child to participate in any activity that you believe you and/or your child cannot perform in accordance with the Valley Friendship Circles activities’ instructions or in a safe manner;
If you observe any significant hazard during your participation in any Event, you will stop participating in the event and inform the Valley Friendship Circle of such hazard immediately;
Release Valley Friendship Circle, the directors, board, officers, activity coordinators, and all employees, volunteers, related parties, and other organizations associated with the activity from any and all claims or liability arising out of this participation provided that care was taken to insure safety;
In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.
I grant the Valley Friendship Circle permission to use my or my child’s name, image, likeness or recording in connection with any promotional materials including, but not limited to, brochures, advertising, and broadcasts. (Optional)
Please sign as appropriate:
PARENT/ GUARDIAN’S NAME: DATE:
PARENT/GUARDIAN SIGNATURE (INITIAL)

PROGRAM FEE
SYMPHONY CIRCLE ANNUAL: $400
SYMPHONY CIRCLE MONTHLY: $40

PAYMENT OPTION
CREDIT CARD INFORMATION
CARDHOLDERS NAME:
VISA MASTER CARD AMEX CC#:
EXP DATE: / CVC:
BILLING ZIP CODE: SIGNATURE (INITIAL):
PLEASE CHARGE MY CARD FOR THE FULL YEAR- $400.00

PLEASE CHARGE MY CARD PER MONTH - $40.00 (FOR THE PREVIOUSLY SELECTED DATES)

TOTAL AMOUNT:

I WOULD LIKE TO HELP ANOTHER FAMILY PARTICIPATE IN VALLEY FRIENDSHIP CIRCLE PROGRAMS WITH A CHARITABLE CONTRIBUTION OF $ .
FOR BILLING MATTERS OR SCHOLARSHIP REQUESTS PLEASE EMAIL US AT INFO@VALLEYFRIENDSHIPCIRCLE.COM. NO ONE WILL BE TURNED AWAY FOR A LACK OF FUNDS.

HEBREW SCHOOL JEWISH BACKGROUND
PLEASE RATE YOUR CHILD’S KNOWLEDGE, TO THE BEST OF YOUR ABILITY
HEBREW ALEF BET:
HEBREW VOWELS AND READING:
HEBREW LANGUAGE/WORDS:
JEWISH FESTIVAL PRACTICES:
JEWISH FESTIVAL HISTORY/MEANING:
DAILY PRAYERS AND BLESSINGS:
TORAH STORIES:
NAME THREE SHORT TERM GOALS FOR YOUR CHILD TO KNOW OR DO IN JEWISH LIFE.
1.
2.
3.
NAME ONE LONG TERM GOAL FOR YOUR CHILD TO KNOW OR DO IN JEWISH LIFE.

AGREEMENTS
I/We are willing to have our contact information shared in the school directory for Hebrew School families.
I/We permit my child's photos to be used to share and publicize our Symphony Circle- Musical Hebrew School program.
Throughout the year there have been parents who have chosen to stay at Hebrew School during school hours to observe. Valley Friendship Circle welcomes parents to stay when necessary. During that time, parents see children exhibit various behaviors, some good and others undesirable. Therefore, we at the Valley Friendship Circle Hebrew School ask that any observation that is made about any child is to remain private and confidential.

QUESTIONS OR COMMENTS:

PARENT/GUARDIAN SIGNATURE (INITIAL) DATE

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