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:

Special Events

Saturday 07/01/23 - 10:AM-12:00PM - Film Production Red Carpet Event

The SPARC Film Production Red Carpet Event is a not-to-be-missed opportunity to celebrate the talents and creativity of participants from the SPARC Community. Join us for an unforgettable event filled with inspiring short films, a chance to meet the incredible filmmakers, and award presentation. This fun and inclusive event is the culmination of our SPARC Film Production Program and is an opportunity to witness the power of storytelling from a diverse perspective.

Weekend Adventures

Friday 05/26/23 to Monday 05/29/23 - Memorial Day Weekend at Camp Jewell!

4 days and 3 nights of fun and adventure await participants at Camp Jewell! All meals are included in this trip as well as outdoor adventures such as Kayaking, Fishing, Climbing, Arts & Crafts and so much more!

Saturday 06/3/23 - 11:00AM-3:00PM - Nature Walk & Scavenger Hunt

Enjoy the beautiful Lenoir Preserve through a self-guided scavenger hunt and activity provided by parks staff. The Lenoir Preserve Nature Center houses many different nature exhibits as well as a Butterfly & Hummingbird Garden. After the scavenger hunt and exploring the preserve participants will enjoy lunch at Fortina Pizza.

Saturday 06/10/23 - 11:30AM-3:30PM - Movie Mixer!

Saturday Movie Mixer: Spider-Man: Across the Spider-Verse! Participants will meet up at Ridge Hill for a Saturday Movie Matinee of the Newest Spider- Man Movie and Mix it up at the Yard House after for lunch with friends.

Sunday 06/11/23 - 12:00PM-4:00PM - Hike with Pygmy Goats at Greenburgh Nature Center

B.Y.O.P. - Bring your own picnic and hike with Pygmy Goats at The Greenburgh Nature Center! Pygmy goats, Maggie and Willow, require a lot of enrichment and exercise to stay happy and healthy. Our SPARC group can provide them with the best possible care by taking them on a forest trail walk with one of the Nature Center's naturalists. Participants will enjoy their picnic lunch after exploring the rest of the Nature Center!

Saturday 06/17/23 - 4:00PM-8:00PM - Black Light Mini Golf & Arcade

Participants will enjoy a fun filled evening at Monster Mini Golf in Ridge Hill - After Black Light Mini Golf and some time in the Arcade Participants will enjoy a delicious dinner at Public Pizza Italian Restaurant.

Saturday 06/24/23 - 6:00PM-9:00PM - Summer Solstice Party!

Celebrate the beginning of Summer at Westmoreland Sanctuary in Mount Kisco! Participants will party the night away and enjoy hordouvres and desserts, a special guided night hike, and a live performance by the School of Rock Band!

Sunday 06/25/23 - 11:00AM-4:00PM - Aqua Adventure At Tibbets Brook Park!

Tibbets Brook Park features one of the most exciting aqua complexes in the country! Participants can enjoy in-pool basketball and volleyball, a dip in one of the lap lanes, and of course the signature Lazy River! Bring your own Picnic or Purchase something yummy at the Snack Bar!

Program Enrollment

Selection #1

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

Link Up: Number of Days

Link Up Extended: Number of Days

Link Up: Which Days?

Monday
Tuesday
Wednesday
Thursday
Friday

Link Up Extended: Which Days?

Monday
Tuesday
Wednesday
Thursday

Season #1*

Location #1

Day(s) of the Week #1:

Please check all that apply.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Summer 1st Program Fee

Please select the SUMMER 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.

Summer 2nd Program Fee

Please select the SUMMER 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.

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.

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.

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

Special Events

Weekend Adventures

Program Enrollment

Participation Consent

Billing Information

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