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 CHILD INFORMATION
First Name:
Last Name:
Grade:
School Attending:
Need to update other information? Please enter below (optional):
Home Phone: Mobile Phone:
Street Address:

City: State: Zip:


Does your child exhibit any of the following behaviors (check all that apply):
Biting Cursing Grabbing Hitting
Kicking Pulling Hair Other:
Is there anything new we need to know about your child?

 SUNDAY CIRCLE / TTYA
11AM - 1PM.  Please check off the dates that you would like your child to join Sunday Circle/TTYA.
OCT 14 OCT 28 NOV 11
NOV 18 DEC 16
JAN 6 JAN 27 FEB 10 FEB 24 MAR 10
MAR 24 MAR 31 MAY 5 MAY 19 JUN 2
CHOOSE ALL OF THE ABOVE DATES        

For youth ages 16-22, there is a special track – Torah Teens And Young Adults. Please check below if this track is applicable.


 HEBREW SCHOOL
 Bring the joys of our traditions to your child in the Hebrew School classroom Sundays 9:00 - 11:00 AM.
Dates: 
Oct 17, 24, 31, Nov 7, 14, 28, Dec 12, 19, Jan 16, 23, 30, Feb 6, 13, 20, 27, March 13, 27, April 3, 10, May 1, 8, 15, June 5


 LET'S PLAY
Tuesdays from 3:00 - 4:00 PM, Ages 4-14.
OCT 30
NOV 27
DEC 4
JAN 15
FEB 5 MAR 5 APR 9  MAY 7
JUN 4            

 HOLIDAY PROGRAMS / SPECIAL EVENTS 2018/19
HOLIDAY CELEBRATIONS:
  Rosh Hashana Festival Sunday, August 26, 2018 from 1:00pm-3:00pm
  Chanukah Bash Sunday, December 2, 2018 from 1:00pm-3:00pm
  Tu B’Shvat festival Sunday, January 20, 2019 from 1:00pm-3:00pm
  Purim Celebration Thursday, March 21, 2019 from 5:30pm-8:00pm
  Matzah Bakery Sunday, April 7, 2019 from 12:00pm-1:00pm
SPECIAL EVENTS:
 

Walk4Friendship LA Sunday October 21, 2018 from 1:30pm-6:00pm. At Shalhevet High School. 910 S. Fairfax Avenue, Los Angeles, Ca 90048

  Mom’s Night Out/Spa For The Soul.  Wednesday, February 27, 2019
  Mom’s Torah & Tea. Wednesdays, 10:30-12 | Nov 14, February 6, March 27

 BOYS BASKETBALL CLUB
  Wednesdays, 6:30-8:00PM
SESSION 1: Oct 17, 24, 31 Nov 7, 14, 28 Dec 12, 19
SESSION 2: Jan 16, 23, 30 Feb 6,13, 20, 27
SESSION 3: March 13, 27 Apr 3, 10 May 1, 8, 15 June 5

 FRIENDS @ HOME PROGRAM
Would you like the volunteers to come and visit your home? YES NO
1st Choice Day: Time:
2nd Choice Day: Time:

 WINTER/END OF SUMMER CAMPS
   If interested in winter or summer camp, please email racheli@fcla.org to receive a separate camp application 
2018 Winter Camp: Monday December 24 - Friday December 28, 2018
2019 Summer Camp: Monday​ August 5 - Friday August 9, 2019

 MEDICAL/INSURANCE
Are there any changes in your child's medical condition/information? YES NO
If YES, please provide details:
Are there any changes in your child's insurance information? YES NO
If YES, please provide details:
Please list any allergies and/or dietary restrictions:

 PROGRAM FEES
Sunday Circle or TTYA: $650
Winter Camp: $450
Summer Camp: $450
Hebrew School: $1,600
Boys Basketball Program: $650 Birthday Bash:  Free
Holiday Programs: Free Friends @ Home:  Free
  For financial aid please email  billing@fcla.org    

 PUBLICITY
Print Materials | Yes    No
Hebrew School | Yes    No
FC Day Class Materials |
Yes    No
Social Media |
Yes    No
Pictures and Posters in FCLA |
Yes    No

 PAYMENT OPTIONS
  No child is turned away due to lack of funds. Please email  billing@fcla.org  for scholarship information. 
CHECK (please make payment to Friendship Circle of Los Angeles and mail to 1952 S. Robertson Blvd, Los Angeles CA 90034)
VISA MASTERCARD AMEX DISCOVER
Cardholder Name: Security Code:
Card Number: Exp. Date:
Total Charge Amount: Billing Zip Code:
Please charge my credit card in the full amount above.
Please charge my credit card $ on the first of the month over the next 10 months. (Billing department approval needed)
Please charge my credit card in two installments of $ on September 1 and December 1.
   
I would like to help another family participate in program
with a charitable contribution of $