Current/Returning Participants

Participant Information

Participant Name*

Please enter first and last name.

Participant's Address

Street Address City State ZIP Code

Participant's Residence Type

Family
Group Home

Agency Name

Birthdate (mm/dd/yy)

Gender

Male
Female

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

Contact Information

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

Emergency Contact Name

Must be different than parent/guardian listed.

Emergency Contact Phone

Personal Information

Self-Care Needs

Disability

Allergies

Adaptive Equipment

Seizures?

Yes
No

Is the participant verbal?

Yes
No

Vision / Hearing Concerns:

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

Program Enrollment

Activity #1*

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

Link Up: Number of Days

Location*

Link Up: Which Days?

Monday
Tuesday
Wednesday
Thursday
Friday

Season*

Day(s) of the Week

Check all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee*

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 2nd activity?*

Yes
No

Activity #2

Season

Location

Day(s) of the Week

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee

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
No

Activity #3

Season

Location

Day(s) of the Week

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Day of the Week

Program Fee

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 in a 4th activity?

Yes
No

Activity #4

Season

Location

Day(s) of the Week

Please select all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Program Fee

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

Payment Method*

Credit Card
Check

Credit Card Transaction Fee Acknowledgement*

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

Check Payment Registration Acknowledgement*

I acknowledge that payment must be made prior to program start date in order for registration to be completed.

Please send a check, made out to "SPARC, Inc.", to SPARC, 40 Triangle Center, Suite 205, Yorktown Heights, NY 10598. Include the participant's name in the subject line.

Transaction Fee*

Price: $0.00

Total

$0.00

Billing Name*

First Last

Billing Address*

Street Address City State ZIP Code

Billing Email*

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.

Upon submission, you will be taken to PayPal to enter your credit card information and complete your transaction Registration is not complete until Paypal payment has been completed.

Current/Returning Participants

Participant Information

Contact Information

Emergency Contact

Personal Information

Program Enrollment

Participation Consent

Billing Information

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