| Name: |
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| Address: |
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| City: |
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State: |
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Zip: |
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| Birthdate: |
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| Parents/Guardians/House Manager: |
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| Home Phone: |
(
)
|
Check
ok to share phone # with group members |
| Work Phone: M |
(
)
|
| Work Phone: F |
(
)
|
| Cell Phone: M |
(
)
|
| Cell Phone: F |
(
)
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| Emergency Phone/Name: |
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| Parent/Guardian E-mail: (required) |
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| Participant E-mail: |
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| Parent Employers: |
M:
F:
|
| SS# (1st time participants only): |
-
-
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| Physical Exam Date: |
|
| Day Program/School/Job: |
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| Disability: |
|
| Medications: |
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| Self Care Needs: |
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| Allergies: |
|
| Adaptive Equipment: |
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| Seizures: |
|
| Vision/Hearing: |
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| Verbal: |
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| Concerns: |
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| More about participant: |
|
| |
I permit
to actively participate in activities as registered on this form and to be given emergency medical treatment in case of injury.
I grant permission for photograph or video images to be used for education use or promotion of SPARC services. Check here if you do not want photo used
, do not want name used
This signature is valid for ongoing enrollment in SPARC programs unless otherwise indicated.
Parent/Guardian/House Manager
Signature:
Date:
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| |
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| |
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*Please be advised the information filled out on this form is done so at your own risk. The form is not being submitted is not SSL certified. Please feel free to follow up with a hard copy of the form in the mail with the social security number and check for enrollment. |
| |
| |
Please make checks payable to
SPARC, Inc. and mail this form to:
SPARC. Inc.. 3045 Gomer Street,
Yorktown Heights, NY 10598
|
For more information or to join
our mailing list, please contact us at
(914) 243-0583
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|
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