Registration Form

Participant Information

1. Participant Name(Required)
2. Address(Required)
3. City, State ZIP(Required)
4. Birthdate (Required)
5. Participant Email Address
6. Day School/Program Job(Required)
7. Social Security Number(Required)
8. Medicaid Number (if applicable)

Contact Information

1. Parents/Guardians/House Manager Name(Required)
2. Home Phone(Required)
3. Work Phone (Mother)(Required)
4. Work Phone (Father)(Required)
5. Cell Phone (Mother)(Required)
6. Cell Phone (Father)(Required)
7. Emergency Name, Phone(Required)
8. Parent/Guardian Email(Valid email required)
9. Employer (Mother)(Required)
10. Employer (Father)(Required)

Personal Information

1. Disability(Required)
2. Physical Exam Date(Required)
3. Medications(Required)
4. Self Care Needs(Required)
5. Allergies(Required)
6. Adaptive Equipment(Required)
7. Seizures(Required)
8. Vision/Hearing(Required)
9. Verbal(Required)
10. Concerns(Required)
11. More about participant

Program Enrollment

1. Activity 1 3D Art Active & Fit Athletic Club Club SPARC Cooking Fun Create-a-Motion Dinner Friends Exploring Art Film Fans Film Production Workshop Gotta Dance Horseback Riding Intro to Golf Kids Express Kidz Time Link-Up Magic of Music Music Lovers Society Pet Connection Rec Night Sensory Themes Sibs Time Social Circle Social Club SPIRIT Summer Magic Teen Time Terrific Times (Required)
2. Season Full Year Spring Summer Fall (Required)
3. Location(Required)
4. Fee(Required)
5. Activity 2 3D Art Active & Fit Athletic Club Club SPARC Cooking Fun Create-a-Motion Dinner Friends Exploring Art Film Fans Film Production Workshop Gotta Dance Horseback Riding Intro to Golf Kids Express Kidz Time Link-Up Magic of Music Music Lovers Society Pet Connection Rec Night Sensory Themes Sibs Time Social Circle Social Club SPIRIT Summer Magic Teen Time Terrific Times
6. Season Full Year Spring Summer Fall
7. Location
8. Fee
9. Activity 3 3D Art Active & Fit Athletic Club Club SPARC Cooking Fun Create-a-Motion Dinner Friends Exploring Art Film Fans Film Production Workshop Gotta Dance Horseback Riding Intro to Golf Kids Express Kidz Time Link-Up Magic of Music Music Lovers Society Pet Connection Rec Night Sensory Themes Sibs Time Social Circle Social Club SPIRIT Summer Magic Teen Time Terrific Times
10. Season Full Year Spring Summer Fall
11. Location
12. Fee
13. Activity 4 3D Art Active & Fit Athletic Club Club SPARC Cooking Fun Create-a-Motion Dinner Friends Exploring Art Film Fans Film Production Workshop Gotta Dance Horseback Riding Intro to Golf Kids Express Kidz Time Link-Up Magic of Music Music Lovers Society Pet Connection Rec Night Sensory Themes Sibs Time Social Circle Social Club SPIRIT Summer Magic Teen Time Terrific Times
14. Season Full Year Spring Summer Fall
15. Location
16. Fee

Participation/Photo Release

1. I permit the participant named above to actively participate in activities as registered on this form and to be transported and given emergency medical treatment in case of injury. I grant permission for photograph or video images to be used for educational use or promotion of SPARC services. Check if you do not want photo used or do not want name used. This signature is valid for ongoing enrollment in SPARC programs unless otherwise indicated.
3. Don't use photo Don't use name
4. By participating in a SPARC program, the parent/guardian of each participant and the participant agree to indemnify, release and hold harmless SPARC, its officers, directors, employees, consultants, agents (including independent contractors, if applicable), and volunteers from any and all liability or causes of action whatsoever arising out of, or which may result from such participation.
5. Parent/Guardian/House Manager:
6. Signature (Please type your name)(Required)
7. Date(Required)
8. I would like to order a 2012 Yearbook for $25
   (Please provide funds with registration payment.) Yes No

 

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Cancellation fees may apply for program withdrawal. Please see our policies on the Registration Information page.

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