New Participants

Current participants form, please click here.

Cancellation fees may apply for program withdrawal. Please see our policies on the Registration Information page.

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 or 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 Phone

Parent / Guardian #2 - Email

Emergency Contact

Emergency Contact Name*

Please enter first and last name.

Emergency Contact Relationship to Participant*

Emergency Contact Phone*

Personal Information

Disability*

Self-Care Needs

Allergies

Adaptive Equipment / Wheelchair

Does the participant have 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*

Link Up MUST be chosen as Activity #1

Link Up: Number of Days

Link Up: Which Days?

Season*

Location

Day(s) of the Week:

Please check all that apply.

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 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.

Would you like to enroll for a 2nd activity?*

Yes
No

Activity #2*

Link Up MUST be chosen as Activity #1

Season

Location

Day(s) of the Week

Please select all that apply.

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

Activity #3*

Link Up MUST be chosen as Activity #1

Season

Location

Day(s) of the Week

Please select all that apply.

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 4th activity?

Yes

Activity #4

Link Up MUST be chosen as Activity #1

Season

Location

Day(s) of the Week

Please select all that apply.

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.

Yes
No

Billing Information

Payment By Credit Card 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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New Participants

Current participants form, please click here.

Participant Information

Contact Information

Emergency Contact

Personal Information

Program Enrollment

Participation Consent

Billing Information

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