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:
Fall / Winter Fun Trips 2022-23 Saturday 01/07/23 11:00AM-4:00PM - Rangers vs. Devils at Prudential Center Please Choose One Saturday 01/07/23 11:00AM-4:00PM - Rangers vs. Devils at Prudential Center - $275(Respite) Saturday 01/07/23 11:00AM-4:00PM - Rangers vs. Devils at Prudential Center - $350 (Non-Respite)
Sunday 01/08/23 11:30AM-3:30PM - Lunch and a Movie Mixer at Cortlandt Town Center Please Choose One Sunday 01/08/23 11:00AM-3:30PM - Lunch and a Movie Mixer at Cortlandt Town Center - $65(Respite) Sunday 01/08/23 11:00AM-3:30PM - Lunch and a Movie Mixer at Cortlandt Town Center - $85 (Non-Respite)
Saturday 01/14/23 4:00PM-7:00PM - Paint, Snack, Trivia & Live Karaoke Party Please Choose One Saturday 01/14/23 4:00PM-7:00PM - Paint, Snack, Trivia & Live Karaoke Party - $65 (Non-Respite) Saturday 01/14/23 4:00PM-7:00PM - Paint, Snack, Trivia & Live Karaoke Party - $85 (Respite)
Sunday 01/22/23 5:00PM-7:30PM - Harry Potter: A Forbidden Forest Experience Please Choose One Sunday 01/22/23 5:00PM-7:30PM - Harry Potter: A Forbidden Forest Experience - $100 (Non-Respite) Sunday 01/22/23 5:00PM-7:30PM - Harry Potter: A Forbidden Forest Experience - $150 (Respite)
Saturday 01/28/23 2:30PM-7:30PM - West Point Hockey Game: Knights vs. Falcons Please Choose One Saturday 01/28/23 2:30PM-7:30PM - West Point Hockey Game: Knights vs. Falcons - $150 (Non-Respite) Saturday 01/28/23 2:30PM-7:30PM - West Point Hockey Game: Knights vs. Falcons - $200 (Respite)
Sunday 01/29/23 2:00PM-5:00PM - Pottery Factory and Frannie's Goody Shop Please Choose One Sunday 01/29/23 2:00PM-5:00PM - Pottery Factory and Frannie's Goody Shop - $50 (Non-Respite) Sunday 01/29/23 2:00PM-5:00PM - Pottery Factory and Frannie's Goody Shop - $75 (Respite)
Saturday 02/04/23 5:00PM-9:00PM - Dinner & Movie Join us for a nice dinner with friends at Lefteris in Mt. Kisco. Then take a short stroll to the Mt. Kisco Theater to enjoy a movie. Film title to be announced
Please Choose One Saturday 02/04/23 5:00PM-9:00PM - Dinner & Movie - $65 (Respite) Saturday 02/04/23 5:00PM-9:00PM - Dinner & Moviep - $85 (Non-Respite)
Sunday 02/05/23 11:00AM-6:00PM - Norwalk Maritime Aquarium Take a relaxing ride on the Metro North from Port Chester, NY train station to beautiful Norwalk, CT. Enjoy lunch, a stroll through the aquarium to learn and interact with aquatic life, both native and from far away places.
Please Choose One Sunday 02/05/23 11:00AM-6:00PM - Norwalk Maritime Aquarium - $100 (Respite) Sunday 02/05/23 11:00AM-6:00PM - Norwalk Maritime Aquarium - $145 (Non-Respite)
Saturday 02/11/23 -10AM-5PM Snow Tubing Take a ride to Campgaw in Mahwah, NJ for a fun day of snow tubing with friends. Lunch and van transportation to & from Tarrytown Train station included.
Please Choose One Saturday 02/11/23 - Snow Tubing - $135 (Respite) Saturday 02/11/23 - Snow Tubing - $200 (Non-Respite)
Sunday 02/12/23 - 5:00PM-9:00PM - The Big Game Party! Join us at the SPARC Office in Yorktown Heights for a fun evening of games, snacks, silly commercials and of course the SuperBowl game.
Please Choose One Sunday 02/12/23 - 5:00PM-9:00PM - The Big Game Party! - $40 (Respite) Sunday 02/12/23 - 5:00PM-9:00PM - The Big Game Party! - $85 (Non-Respite)
Friday 02/17/23 6:15PM-9:15PM - Valentine's Day Dance Briarcliff Middle School Cafeteria 444 Pleasantville Rd Briarcliff Manor, NY 10510 - Music by: DJ Slinger
Please Choose One Friday 02/17/23 6:15PM-9:15PM - Valentine's Day Dance - $25 (Respite) Friday 02/17/23 6:15PM-9:15PM - Valentine's Day Dance - $35 (Non-Respite)
Saturday 02/18/23 - 12:00PM-4:00PM - Indoor Golf, Lunch & Window Meet us at The Westchester Mall in White Plains for lunch at the food court, check out the new indoor driving range and take a leisurely stroll through the mall. Do some window shopping or buy yourself a little something.
Please Choose One Saturday 02/18/23 - 12:00PM-4:00PM - Indoor Golf, Lunch & Window - $80 (Respite) Saturday 02/18/23 - 12:00PM-4:00PM - Indoor Golf, Lunch & Window - $100 (Non-Respite)
Sunday 02/19/23 - 12:00PM-4:00PM - Bowling, Lunch & Arcade Meet us at SPINS in Mt. Kisco and get ready for some friendly competition. A few games of bowling, a meal, and test your gaming skills and enjoy the entertainment at the arcade.
Please Choose One Sunday 02/19/23 - 12:00PM-4:00PM - Bowling, Lunch & Arcade - $90 (Respite) Sunday 02/19/23 - 12:00PM-4:00PM - Bowling, Lunch & Arcade - $120 (Non-Respite)
Saturday 02/25/23 - 11:00AM-5:00PM - Katz's Deli & Museum of Ice Cream Meet us at the White Plains Train Station and take a ride into NYC to enjoy lunch at the famous Katz's Deli and a quick stroll to fun at the nearby Museum of Ice Cream. Lunch and van transportation provided.
Please Choose One Saturday 02/25/23 - 11:00AM-5:00PM - Katz's Deli & Museum of Ice Cream - $150 (Respite) Saturday 02/25/23 - 11:00AM-5:00PM - Katz's Deli & Museum of Ice Cream - $175 (Non-Respite)
Sunday 02/28/23 - 11:30AM-3:30PM - Tea Party & Retro Arcade Meet us at Croton Corners in Croton-on-Hudson, NY. Place offers tea and traditional tea-party fare. Other food & beverages available for non-tea drinkers. Then, spend some time enjoying the retro arcade that includes NES, Super Nintendo, PACMAN, Wii & more!
Please Choose One Sunday 02/28/23 - 11:30AM-3:30PM - Tea Party & Retro Arcade - $90 (Respite) Sunday 02/28/23 - 11:30AM-3:30PM - Tea Party & Retro Arcade - $120 (Non-Respite)
Program Enrollment Selection #1 If choosing Link Up, it must be chosen as Selection #1
Please choose one Link Up Link Up Extended VIRTUAL: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens
Link Up: Number of Days Select 1 2 3 4 5
Link Up Extended: Number of Days Select 1 2 3 4
Link Up: Which Days? Link Up Extended: Which Days? Season #1* Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) LIVE: Horseback Riding 10:45:am - $515 (Non-Respite) Live: SPIRIT - FREE NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-Respite) LIVE: Club SPARC - $525 (Non-Respite) LIVE: Club SPARC - $385 (Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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
Link-up Extended 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.
Please Choose One 4 Days Each Week Respit - $200 4 Days Each Week Non-Respit - $222.08 3 Days Each Week Respit - $150 3 Days Each Week Non-Respit - $166.56 2 Days Each Week Respit - $100 2 Days Each Week Non-Respit - $111.04 1 Day Each Week Respit - $50 1 Day Each Week Non-Respit - $55.52
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: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens Link Up
Season #2 Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:00am - $515 (Non-Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) Live: SPIRIT - FREE NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-Respite) LIVE: Club SPARC - $525 (Non-Respite) LIVE: Club SPARC - $385 (Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens Link Up
Season #3 Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:00am - $515 (Non-Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) Live: SPIRIT - FREE NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-RNOT AVAILABLE!! espite) LIVE: Club SPARC - $525 (Non-Respite) LIVE: Club SPARC - $385 (Respite) LIVE: Social Club - $500 (Non-Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens Link Up
Season #4 Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:00am - $515 (Non-Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) LIVE: Club SPARC $550 Live: SPIRIT - FREE NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-Respite) LIVE: Club SPARC - $525 (Non-Respite) LIVE: Club SPARC - $385 (Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens Link Up
Season #5 Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:00am - $515 (Non-Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) Live: SPIRIT - FREE NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Non-Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-Respite) LIVE: Club SPARC - $525 nonrespite rate LIVE: Club SPARC - $385 (Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens Link Up
Season #6 Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:00am - $515 (Non-Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) Live: SPIRIT - FREE LIVE: Fall 2021 Miniature Golf - $275 (Non-Respite) LIVE: Fall 2021 Miniature Golf - $175 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-Respite) LIVE: Club SPARC - $525 (Non-Respite) LIVE: Club SPARC - $385 (Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens Link Up
Season #7 Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:00am - $515 (Non-Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) Live: SPIRIT - FREE NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-Respite) LIVE: Club SPARC - $525 (Non-Respite) LIVE: Club SPARC - $385 (Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens Link Up
Season #8 Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:00am - $515 (Non-Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) Live: SPIRIT - FREE NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-Respite) LIVE: Club SPARC - $525 (Non-Respite) LIVE: Club SPARC - $385 (Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens Link Up
Season #9 Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:00am - $515 (Non-Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) Live: SPIRIT - FREE NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-Respite) LIVE: Club SPARC - $525 (Non-Respite) LIVE: Club SPARC - $385 (Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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: Lifeskills VIRTUAL: Art VIRTUAL: Movie Night/Netflix & Friends VIRTUAL: Virtual Games Night LIVE: Horseback Riding LIVE: Club SPARC LIVE: Culinary Creations LIVE: Mingle and Dine Live: SPIRIT LIVE: Social Club LIVE: Social Circle for Adults LIVE: 15 Week Film Production Workshop Fall/Spring Only LIVE: 30 Week Film Production Workshop Fall/Spring Only LIVE: Golf Clinic LIVE: Teen Time LIVE: Tennis Hotshots Fall/Spring Only LIVE: Bowling LIVE: Independence Day Virtual Dance Party LIVE: Winter Break Drumming Workshop for Teens Link Up
Season #10 Select Fall 2022 Winter 2023 Spring 2023 Summer 2023
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: Lifeskills - $470 nonrespite rate VIRTUAL: Lifeskills - $270 (Respite) VIRTUAL: Art - $470 nonrespite rate VIRTUAL: Art - $270 (Respite) VIRTUAL: Movie Night/Netflix & Friends - $420 nonrespite rate VIRTUAL: Movie Night/Netflix & Friends - $240 (Respite) VIRTUAL: Virtual Games Night - $270 (Respite) VIRTUAL: Virtual Games Night - $470 (Non-Respite) LIVE: Horseback Riding 10:00am - $300 (Respite) LIVE: Horseback Riding 10:45am - $300 (Respite) LIVE: Horseback Riding 10:00am - $515 (Non-Respite) LIVE: Horseback Riding 10:45am - $515 (Non-Respite) Live: SPIRIT - FREE NOT AVAILABLE!! LIVE: Miniature Golf - $275 (Respite) NOT AVAILABLE!! LIVE: Miniature Golf - $325 (Non-Respite) LIVE: Club SPARC - $525 (Non-Respite) LIVE: Club SPARC - $385 (Respite) LIVE: Culinary Creations - $375 (Non-Respite) LIVE: Culinary Creations - $285 (Respite) LIVE: Mingle and Dine - $500 (Respite) LIVE: Mingle and Dine - $650 (Non-Respite) LIVE: Social Club - $385 (Respite) LIVE: Social Club - $525 (Non-Respite) LIVE: Social Club 30 Weeks - $730 (Respite) LIVE: Social Circle for Adults - $385 (Respite) LIVE: Social Circle for Adults - $525 (Non-Respite) LIVE: Social Circle for Adults 30 Weeks - $730 (Respite) LIVE: 15 Week Film Production Workshop - $400 (Respite) LIVE: 15 Week Film Production Workshop - $650 (Non-Respite) LIVE: 30 Week Film Production Workshop - $765 (Respite) LIVE: Golf Clinic - $250 (Non-Respite) LIVE: Golf Clinic - $150 (Respite) LIVE: Teen Time - $385 (Respite) LIVE: Teen Time - $525 (Non-Respite) LIVE: Teen Time 30 Weeks - $730 (Respite) LIVE: Tennis Hotshots - $485 (Non-Respite) LIVE: Tennis Hotshots - $400 (Respite) LIVE: 15 Week Bowling - $550 (Non-Respite) LIVE: 15 Week Bowling - $400 (Respite) LIVE: 30 Week Bowling - $750 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $25 (Respite) NOT AVAILABLE!! LIVE: Independence Day Virtual Dance Party - $35 (Non-Respite) NOT AVAILABLE!! LIVE: Winter Break Drumming Workshop for Teens - Free
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*
First
Last
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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