• Registration Info
• Registration Form: Lakeland
• Registration Form: Somers
• Registration Form: Yorktown

• Volunteer

• Donate Now!

• Magic of Music

Registration Form – Lakeland

Participant Information

1. Name(Required)
2. Birthdate(Required)
3. Age(Required)
4. School(Required)
5. Grade(Required)
6. Teacher(Required)
7. Bus #/Route(Required)
8. Student Address(Required)
9. City, State ZIP Code(Required)
10. Allergies
11. Special Conditions

Contact Information

1. Parent/Guardian 1 Name(s)(Required)
2. Parent/Guardian 2 Name(s)(Required)
3. Parent/Guardian 1 Email Address(es)(Email required)
4. Parent/Guardian 2 Email Address(es)(Required)
5. Home Phone (1)(Required)
6. Home Phone (2)(Required)
7. Work Phone (Mom)(Required)
8. Work Phone (Dad)(Required)
9. Cell Phone (Mom)(Required)
10. Cell Phone (Dad)(Required)
11. Emergency Contact (Name, relationship)(Required)
12. Phone(Required)
13. Alternate Pick Up (Name, relationship)(Required)
14. Phone(Required)

Program Information

1. Please mark areas you would like your child to work on: (optional)
2. 1. Initiating & Maintaining Conversation
   2. Getting Along with Others (Cooperation)
   3. Being a Good Friend
   4. Understanding & Dealing with Feelings (self-esteem)
   5. Handling Social Conflicts
   6. Problem Solving (Collaboration/Compromise)
3. Are there additional social skills you’d like your child to learn more about? Please list.
4. Other information
5. Has your child previously participated in Kids Express?
6. 1. Yes
   2. No
7. If yes, when?

Signature

1. I permit my child to actively participate in SPARC’s Kids Express and be dismissed to above names. I permit SPARC the option to contact my child’s teacher to assist program plans. I permit my child’s photograph to be used in SPARC publicity.
2. Initial to omit your name from publicity
3. Guardian Signature(Required)
4. Date(Required)
5. Send me a copy please

 

cforms contact form by delicious:days

Please note:
If you are using Internet Explorer 6.0, this form will not submit electronically. Please print and mail this form instead.