Participant Information Participant Name* Please enter first and last name.
Has Your Address Changed?* Participant's Address
Participant's Residence Type Agency Name
Job / Program (Adults) OR School / Grade / Teacher (Youth)
Contact Information Has Parent / Guardian / House Manager Changed?* 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? 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?* Emergency Contact Name Must be different than parent/guardian listed.
Emergency Contact Phone
Personal Information Has Your Personal Information Changed?* Self-Care Needs
Allergies
Adaptive Equipment
Seizures? Vision / Hearing Concerns:
More information you would like us to know about the participant:
Spring Adventure Trips 2021 4/10/21 10:00am-3:00pm Artists Corner Part 2 @ White Plains (Art project, walk into town, lunch, yoga, yummy treat, social time and more)
Please Choose One 4/10/21 10:00am-3:00pm Artists Corner Part 2 @ White Plains - $100 4/10/21 10:00am-3:00pm Artists Corner Part 2 @ White Plains - $45 (Respite)
4/11/21 1:00pm-5:00pm Healthy and Fit @ JCC-Tarrytown (Recreation, fitness w/a professional trainer, gymnasium, workshops, lunch, social time and more)
Please Choose One 4/11/21 1:00pm-5:00pm Healthy and Fit @ JCC-Tarrytown - $100 4/11/21 1:00pm-5:00pm Healthy and Fit @ JCC-Tarrytown - $45 (Respite)
4/17/21 10:00am-3:00pm Film Makers @ SPARC Office-Yorktown (Filming a commercial for SPARC, social time, recreation, lunch, outdoor fun and more). Special Guest.
Please Choose One 4/17/21 10:00am-3:00pm Film Makers @ SPARC Office-Yorktown - $100 4/17/21 10:00am-3:00pm Film Makers @ SPARC Office-Yorktown - $45 (Respite)
4/24/21 10:00am-3:00pm 1950’s Theme Party Jam-White Plains (Socially distant party, music, recreation, social time, 50’s Memorabilia, walk into town, lunch and more)
Please Choose One 4/24/21 10:00am-3:00pm 1950’s Theme Party Jam-White Plains - $100 4/24/21 10:00am-3:00pm 1950’s Theme Party Jam-White Plains - $45 (Respite)
Saturday 5/1/21 2:00pm-7:00pm Westmorelands-Mt. Kisco, NY (Workshops, nature trails, tour of the facility and grounds, learn about birds, lunch on the picnic grounds, volunteer work and more)
Please Choose One Saturday 5/1/21 2:00pm-7:00pm Westmorelands-Mt. Kisco, NY - $120 Saturday 5/1/21 2:00pm-7:00pm Westmorelands-Mt. Kisco, NY - $60 (Respite)
Saturday 5/8/21 2:00pm-7:00pm Mini-Golf Park Fun @ Tibbetts Brook Park-Yonkers, NY (Trails/hikes, hot lunch, mini golf, ice breakers, recreation, life skills, social time and more)
Please Choose One Saturday 5/8/21 2:00pm-7:00pm Mini-Golf Park Fun @ Tibbetts Brook Park-Yonkers, NY - $120 Saturday 5/8/21 2:00pm-7:00pm Mini-Golf Park Fun @ Tibbetts Brook Park-Yonkers, NY - $60 (Respite)
Saturday 5/15/21 2:00pm-7:00pm Teatown Reservation-Ossining, NY (Reserve trails and hiking, exploring with a tour guide, nature fun, lunch, workshop and more)
Please Choose One Saturday 5/15/21 2:00pm-7:00pm Teatown Reservation-Ossining, NY - $120 Saturday 5/15/21 2:00pm-7:00pm Teatown Reservation-Ossining, NY - $60 (Respite)
Saturday 5/22/21 2:00pm-7:00pm Gedney Park-Chappaqua, NY (Hikes and trails, recreation, social time, games, lunch, view of the water, dessert and more)
(Rain Date Sunday 5/23/21)
Please Choose One Saturday 5/22/21 2:00pm-7:00pm Gedney Park-Chappaqua, NY - $100 Saturday 5/22/21 2:00pm-7:00pm Gedney Park-Chappaqua, NY - $45 (Respite)
Saturday 6/5/21 2:00pm-7:00pm Learn to Budget-Richard Pressler Park-Scarsdale, NY (Life Skills, learning to budget, walking, lunch, window shopping, social time, recreation, games and more)
Please Choose One Saturday 6/5/21 2:00pm-7:00pm Learn to Budget-Richard Pressler Park-Scarsdale, NY - $100 Saturday 6/5/21 2:00pm-7:00pm Learn to Budget-Richard Pressler Park-Scarsdale, NY - $45 (Respite)
Saturday 6/12/21 1:30pm-6:30pm Ridge Hill Mall-Yonkers, NY (Outdoor fun, mall cardio, lunch, dessert, group selfies, scavenger hunt, recreation, social time and more)
Please Choose One Saturday 6/12/21 1:30pm-6:30pm Ridge Hill Mall-Yonkers, NY - $100 Saturday 6/12/21 1:30pm-6:30pm Ridge Hill Mall-Yonkers, NY - $45 (Respite)
Saturday 6/19/21 2:00pm-7:00pm Banquet and a Screenplay-White Plains, NY (Live movie @ the City Center Theater, life skills, social time, recreation, lunch, window shopping and
Please Choose One Saturday 6/19/21 2:00pm-7:00pm Banquet and a Screenplay-White Plains, NY - $120 Saturday 6/19/21 2:00pm-7:00pm Banquet and a Screenplay-White Plains, NY - $60 (Respite)
Saturday 6/26/21 1:30pm-6:30pm Beautiful Day in the Neighborhood Part 2 Ossining, NY (Exploring Ossining, waterfall trail, lunch at the beach, social and recreation time, dessert, games and more)
Please Choose One Saturday 6/26/21 1:30pm-6:30pm Beautiful Day in the Neighborhood Part 2 Ossining, NY - $100 Saturday 6/26/21 1:30pm-6:30pm Beautiful Day in the Neighborhood Part 2 Ossining, NY - $45 (Respite)
Program Enrollment Selection #1 If choosing Link Up, it must be chosen as Selection #1
Please choose one Link Up VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time
Link Up: Number of Days Select 1 2 3 4 5
Link Up: Which Days? Season #1* Select Summer 2021 Spring 2021 Winter
Location #1
Day(s) of the Week #1: Please check all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
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.
Please Choose One 5 Days Each Week - $700 4 Days Each Week - $600 3 Days Each Week - $400 2 Days Each Week - $325 1 Day Each Week - $250 Non-Medicaid Inquiry
Would you like to enroll for a 2nd activity?* Selection #2* If choosing Link Up, it must be chosen as Selection #1
Please choose one VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time Link Up
Season #2 Select Summer 2021 Spring 2021 Winter
Location #2
Day(s) of the Week #2 Please select all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
Would you like to enroll for a 3rd activity? Selection #3 If choosing Link Up, it must be chosen as Selection #1
Please choose one VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time Link Up
Season #3 Select Summer 2021 Spring 2021 Winter
Location #3
Day(s) of the Week #3 Please select all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
Would you like to enroll for a 4th activity? Selection #4 If choosing Link Up, it must be chosen as Selection #1
Please choose one VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time Link Up
Season #4 Select Summer 2021 Spring 2021 Winter
Location #4
Day(s) of the Week #4 Please select all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
Would you like to enroll for a 5th activity? Selection #5 If choosing Link Up, it must be chosen as Selection #1
Please choose one VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time Link Up
Season #5 Select Summer 2021 Spring 2021 Winter
Location #5
Day(s) of the Week #5 Please select all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
Would you like to enroll for a 6th activity? Selection #6 If choosing Link Up, it must be chosen as Selection #1
Please choose one VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time Link Up
Season #6 Select Summer 2021 Spring 2021 Winter
Location #6
Day(s) of the Week #6 Please select all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
Would you like to enroll for a 7th activity? Selection #7 If choosing Link Up, it must be chosen as Selection #1
Please choose one VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time Link Up
Season #7 Select Summer 2021 Spring 2021 Winter
Location #7
Day(s) of the Week #7 Please select all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
Would you like to enroll for a 8th activity? Selection #8 If choosing Link Up, it must be chosen as Selection #1
Please choose one VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time Link Up
Season #8 Select Summer 2021 Spring 2021 Winter
Location #8
Day(s) of the Week #8 Please select all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
Would you like to enroll for a 9th activity? Selection #9 If choosing Link Up, it must be chosen as Selection #1
Please choose one VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time Link Up
Season #9 Select Summer 2021 Spring 2021 Winter
Location #9
Day(s) of the Week #9 Please select all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
Would you like to enroll for a 10th activity? Selection #10 If choosing Link Up, it must be chosen as Selection #1
Please choose one VIRTUAL: Karate with Master Wayne VIRTUAL: Lifeskills with Kara VIRTUAL: Virtual Games with Gwyn VIRTUAL: Active and Fit VIRTUAL: Art with Kara VIRTUAL: Dance Movement VIRTUAL: No Bake Cooking VIRTUAL: Breakfast Club VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Beat Box Body Movement LIVE: Horseback Riding LIVE: Miniature Golf LIVE: Club SPARC LIVE: Theatre with Blaire LIVE: Social Club LIVE: Girls Empowerment LIVE: Film Production Workshop LIVE: Golf Clinic LIVE: Teen Time Link Up
Season #10 Select Summer 2021 Spring 2021 Winter
Location #10
Day(s) of the Week #10 Please select all that apply.
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.
Please Choose One VIRTUAL: Karate with Master Wayne - $485 nonrespite rate VIRTUAL: Karate with Master Wayne: Karate with Master Wayne - $275 (Respite) VIRTUAL: Lifeskills with Kara - $450 nonrespite rate VIRTUAL: Lifeskills with Kara - $250 (Respite) VIRTUAL: Virtual Games with Gwyn - $450 nonrespite rate VIRTUAL: Virtual Games with Gwyn - $250 (Respite) VIRTUAL: Active and Fit - $485 nonrespite rate VIRTUAL: Active and Fit - $275 (Respite) VIRTUAL: Art with Kara - $485 nonrespite rate VIRTUAL: Art with Kara - $275 (Respite) VIRTUAL: Dance Movement - $450 nonrespite rate VIRTUAL: Dance Movement - $250 (Respite) VIRTUAL: No Bake Cooking - $450 nonrespite rate VIRTUAL: No Bake Cooking - $250 (Respite) VIRTUAL: Breakfast Club - $0 VIRTUAL: Movie Night/Netflix & Friends - $450 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $250 (Respite) VIRTUAL: Beat Box Body Movement - $0 LIVE: Horseback Riding - $550 nonrespite rate LIVE: Horseback Riding - $320 (Respite) LIVE: Miniature Golf - $625 nonrespite rate LIVE: Miniature Golf - $250 (Respite) LIVE: Club SPARC - $485 nonrespite rate LIVE: Club SPARC - $275 (Respite) LIVE: Theatre with Blaire - $350 nonrespite rate LIVE: Theatre with Blaire - $250 (Respite) LIVE: Social Club - $550 nonrespite rate LIVE: Social Club - $350 (Respite) LIVE: Girls Empowerment - $375 nonrespite rate LIVE: Girls Empowerment - $250 (Respite) LIVE: Film Production Workshop - 15 weeks - $625 nonrespite rate LIVE: Film Production Workshop - 15 weeks - $385 (Respite) LIVE: Golf Clinic - $300 nonrespite rate LIVE: Golf Clinic - $200 (Respite) LIVE: Teen Time - $550 LIVE: Teen Time - $350 (Respite)
Participation Consent Participation Consent:* The participant has permission to participate in the activities registered for on this form.
Communication Consent:* I consent to receiving emails and/or text messages about the participant listed on this form.
In the event of an emergency:* I consent to allowing the participant to be transported and treated at the nearest medical facility.
Photography Consent* I consent to photographs or videos of the participant being used for educational or SPARC promotion.
Billing Information Credit Card Transaction Fee Acknowledgement* Transaction Fee*
Price: $0.00
Total
$0.00
Billing Name*
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Billing Address*
Billing Phone*
Billing Email*
Credit Card 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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