Sparc Inc. - Registration Form

Registration 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:

Address:

Guardian Email:

Guardian 2:

E-mail:

Participant
E-mail:

Home Phone:

Cell:

Work Phone:

Physical
Exam Date:

Birthdate:

Emergancy
Contact/Phone:

SSN*:

- -

Disability:

Medications:

Self Care Needs:

Concerns:

Day Program/
Job / School:

Allergies:

Adaptive
Equipment:

Seizures:

Vision / Hearing:

Verbal:

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 educational use or promotion of SPARC services.

Please check if you would like name omitted from publicity ____.

Guardian Signature: Date:

Activity

Season

Location

Fee

Full Year
Spring
Summer
Fall

*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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