Sparc Inc. - Kid Registration

Kids Express
Student Information Form

By completing this form online we are able to hold your place, however this form needs to be signed, printed and mailed along with a check to fully complete the process.

Name:

E-Mail:

Birthdate:

School:

Bus No./Route:

Child's
Grade:

Student Address:

Teacher:

Town:

Parent/Guard.

Daytime Phone:

Other:

Parent/Guard.

Daytime Phone:

Other:

Emergency Contact:

Daytime Phone:

Other:

Alternate Pick-up
(relation to student)

Telephone:

Alternate Pick-up
(relation to student)

Telephone:

Allergies:

Strengths / Diffculties

Social Skills I'd like my child to learn more about:

Other information:

Participation Release:

I permit my child to actively participate in Kids Express and be dismissed to above names.
Guardian Signature_______________________ Date___________

I permit Kids Express option to contact my child's teacher to assist program plans.
Guardian Signature__________________Date_________________

I permit my child's photograph to be used in Kids Express publicity.
Guardian Signature_____________________ Date___________

Return Form with check payable to:
SPARC. Inc.. 3045 Gomer Street, Yorktown Heights, NY 10598

For more information please do not hesitate to contact us (914) 243-0583

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