Current/Returning Participants

Participant Information

Participant Name*

Please enter first and last name.

Has Your Address Changed?*

Yes
No

Participant's Address

Street Address City State ZIP Code

Participant's Residence Type

Family
Group Home

Agency Name

Job / Program (Adults) OR School / Grade / Teacher (Youth)

Contact Information

Has Parent / Guardian / House Manager Changed?*

Yes
No

Parent/Guardian #1 / House Manager - Name

Please enter first and last name.

Parent / Guardian #1 Home Phone

Parent / Guardian #1 Cell Phone

Parent / Guardian #1 - Email*

Would you like to add another parent/guardian?

Yes
No

Parent / Guardian #2 Name

Please enter first and last name.

Parent / Guardian #2 Home Phone

Parent / Guardian #2 Cell Phone

Parent / Guardian #2 - Email

Emergency Contact

Has Your Emergency Contact Changed?*

Yes
No

Emergency Contact Name

Must be different than parent/guardian listed.

Emergency Contact Phone

Personal Information

Has Your Personal Information Changed?*

Yes
No

Self-Care Needs

Allergies

Adaptive Equipment

Seizures?

Yes
No

Vision / Hearing Concerns:

More information you would like us to know about the participant:

Fall Adventure Trips 2020

Fall Adventure Trip 2020 - Respite

Price: $45.00 Quantity:

Fall Adventure Trip 2020 - Non-Respite

Price: $100.00 Quantity:

Fall Adventure Trip(s) 2020

Please list the dates of the Fall Adventure Trip(s) that you would like to attend.

Fall Adventure Trip 2020 - Alamo or Paint/Sip (Respite)

Price: $50.00 Quantity:

Fall Adventure Trip 2020 - Alamo or Paint/Sip (Non-Respite)

Price: $110.00 Quantity:

Program Enrollment

Selection #1*

If choosing Link Up, it must be chosen as Selection #1

Link Up: Number of Days

Link Up: Which Days?

Monday
Tuesday
Wednesday
Thursday
Friday

Season #1*

Location #1

Day(s) of the Week #1:

Please check all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #1*

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Link-up Program Fee*

Please select number of days the participant will attend program each week. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Would you like to enroll for a 2nd activity?*

Yes
No

Selection #2*

If choosing Link Up, it must be chosen as Selection #1

Season #2

Location #2

Day(s) of the Week #2

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #2

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Would you like to enroll for a 3rd activity?

Yes

Selection #3

If choosing Link Up, it must be chosen as Selection #1

Season #3

Location #3

Day(s) of the Week #3

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #3

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Would you like to enroll for a 4th activity?

Yes

Selection #4

If choosing Link Up, it must be chosen as Selection #1

Season #4

Location #4

Day(s) of the Week #4

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #4

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Would you like to enroll for a 5th activity?

Yes

Selection #5

If choosing Link Up, it must be chosen as Selection #1

Season #5

Location #5

Day(s) of the Week #5

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #5

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Would you like to enroll for a 6th activity?

Yes

Selection #6

If choosing Link Up, it must be chosen as Selection #1

Season #6

Location #6

Day(s) of the Week #6

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #6

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Would you like to enroll for a 7th activity?

Yes

Selection #7

If choosing Link Up, it must be chosen as Selection #1

Season #7

Location #7

Day(s) of the Week #7

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #7

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Would you like to enroll for a 8th activity?

Yes

Selection #8

If choosing Link Up, it must be chosen as Selection #1

Season #8

Location #8

Day(s) of the Week #8

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #8

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Would you like to enroll for a 9th activity?

Yes

Selection #9

If choosing Link Up, it must be chosen as Selection #1

Season #9

Location #9

Day(s) of the Week #9

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #9

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Would you like to enroll for a 10th activity?

Yes

Selection #10

If choosing Link Up, it must be chosen as Selection #1

Season #10

Location #10

Day(s) of the Week #10

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee #10

Please select the program you are registering for. The price will be displayed in the "total" field at the bottom of the page. Prices reflect Medicaid Respite eligibility. For non-medicaid prices please inquire.

Participation Consent

Participation Consent:*

The participant has permission to participate in the activities registered for on this form.

Yes
No

Communication Consent:*

I consent to receiving emails and/or text messages about the participant listed on this form.

Yes
No

In the event of an emergency:*

I consent to allowing the participant to be transported and treated at the nearest medical facility.

Yes
No

Photography Consent*

I consent to photographs or videos of the participant being used for educational or SPARC promotion.

I consent
I do not consent

Billing Information

Credit Card Transaction Fee Acknowledgement*

I acknowledge that all credit card transactions are subject to a 3% transaction fee.

Transaction Fee*

Price: $0.00

Total

$0.00

Billing Name*

First Last

Billing Address*

Street Address City State ZIP Code

Billing Phone*

Billing Email*

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Parent / Guardian / Agency Signature*

My signature is valid for ongoing enrollment in SPARC unless otherwise indicated.

By participating in SPARC programs, 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.

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Current/Returning Participants

Participant Information

Contact Information

Emergency Contact

Personal Information

Fall Adventure Trips 2020

Program Enrollment

Participation Consent

Billing Information

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