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.
Link-up Program Fee*
Please select the number of days each week 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
If choosing Link Up, it must be chosen as Activity #1
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
If choosing Link Up, it must be chosen as Activity #1
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 in a 4th activity?
- Yes
- No
Activity #4
If choosing Link Up, it must be chosen as Activity #1
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
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

Program Enrollment

Participation Consent

Billing Information

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