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Cancellation fees may apply for program withdrawal. Please see our policies on the Registration Information page.
Participant Information
Please enter first and last name.
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Contact Information
Please enter first and last name.
Please enter first and last name.
Emergency Contact
Please enter first and last name.
Personal Information
Program Enrollment
If choosing Link Up, it must be chosen as Selection #1
Please check all that apply.
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 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.
If choosing Link Up, it must be chosen as Selection #1
Please select all that apply.
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.
If choosing Link Up, it must be chosen as Selection #1
Please select all that apply.
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.
If choosing Link Up, it must be chosen as Selection #1
Please select all that apply.
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.
If choosing Link Up, it must be chosen as Selection #1
Please select all that apply.
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.
If choosing Link Up, it must be chosen as Selection #1
Please select all that apply.
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.
If choosing Link Up, it must be chosen as Selection #1
Please select all that apply.
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.
If choosing Link Up, it must be chosen as Selection #1
Please select all that apply.
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.
If choosing Link Up, it must be chosen as Selection #1
Please select all that apply.
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.
If choosing Link Up, it must be chosen as Selection #1
Please select all that apply.
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
The participant has permission to participate in the activities registered for on this form.
I consent to receiving emails and/or text messages about the participant listed on this form.
I consent to allowing the participant to be transported and treated at the nearest medical facility.
I consent to photographs or videos of the participant being used for educational or SPARC promotion.
Billing Information
Price: $0.00
$0.00
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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.
