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:
Participant Full Name*
How did you hear about us?*
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?
Please list some of your child/teen's interests/hobbies*:
Participant Date of Birth*
Street Address 1*
Street Address 2
High School Graduation Year*
Mother's Full Name*
Father's Full Name*
Emergency Contact Full Name*
Relationship To Child*
Physician's Phone Number*
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
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