Welcome Jewish families of northern Virginia!

If you have a child or teen with a disability who could benefit from a Jewish friend visiting your home on a weekly basis during the school year, please register your child or teen by filling out the form below to begin the matching process:

Friends@Home Participant Information

Participant Full Name*

MaleFemale

How did you hear about us?*
FacebookInstagramGoogleReferral

Who told you about us?*

Days Available for a 1-hour visit:
Monday (after school)Tuesday (after school)Wednesday (after school)Thursday (after school)Sunday

Why do you want to participate in Friendship Circle Northern Virginia?

Congregation*

Please list some of your child/teen's interests/hobbies*:

Participant Date of Birth*

MaleFemale

Street Address 1*

Street Address 2

City*

State*

Zipcode*

Home Phone*

Teen Mobile

Teen Email

School*

High School Graduation Year*

Parent Information

Mother's Full Name*

Email*

Mobile*

Occupation*

Father's Full Name*

Email*

Mobile*

Occupation*

Emergency Contact and Medical Information

Emergency Contact Full Name*

Relationship To Child*

Cell Phone*

Physician's Name*

Physician's Phone Number*

Health Insurance*

Policy Number*

Additional Medical Information

Medications*

Allergies

Dietary Restrictions

Comments

We create info cards with the following useful information for volunteers at FriendsTogether to have before meeting your child/teen so they can have the most fun possible!

Does your child/teen have any food allergies or restrictions?*

Does your child/teen have any medical conditions that may need to be addressed (Ex: insulin injections, history of seizures, etc.)?*

How much/what kind of help does your child/teen need in bathroom?*

Does your child/teen have any mobility constraints? If so, what are some methods used to aid your child?*

Does your child/teen have triggers such as topics of conversation to avoid, sensory triggers, etc.? If so, what are they?*

In the event that your child/teen is triggered, what are some effective calming techniques that can be used? Please include any behavior management reward systems or phrases that help your child/teen refocus.*

What methods does your child/teen use to communicate? Are there any helpful signs to know?*

What type of activities or part of our program do you think your child/teen will need assistance with? (Ex: transitions, small motor, fine motor, large motor, etc...)*

Is there any other information that you wish to share with the FC volunteers?

Is there any other information you would like to share with the FC staff?

I hereby give my son/daughter permission to participate in Friendship Circle

I agree that a parent/guardian will be present in the home to supervise my child and the volunteer(s) if my child participates in the Friends@Home program.

I understand that my son's/daughter's photograph may be taken and may be used for promotional purposes

Where applicable, I permit my child to be transported by the Friendship Circle to and from activities.

I hereby release Friendship Circle, its providers, and administrators from ALL liability resulting from any incident which affects the health, welfare, or safety of my child while participating in a Friendship Circle program for the year 2023-2024.

I agree to subscribe to the monthly Friendship Circle Northern Virginia newsletter

Friends@Home Registration