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Registration Info
Magic of Music, Spirit & Little Spirit
Somers
Want to register for Magic of Music or SPIRIT? Please
click here
to register.
* Required field
Participant Information
Name
*
Birthdate (mm/dd/yy)
*
Age
*
Gender
*
Male
Female
School
*
Grade
*
Teacher
*
Bus # / Route
*
Student's Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
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Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
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New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Allergies
Special Conditions
Does your child have an IEP?
Yes
Social Security Number OR Medicaid TABS Number
Medicaid Waiver
My child has Medicaid waiver
Contact Information
Parent / Guardian #1 - Name
*
Parent/Guardian #1 - Email
*
Parent / Guardian #1 - Home Phone
Parent / Guardian #1 - Work Phone
Parent / Guardian #1 - Cell Phone
Would you like to add another parent or guardian's information?
Yes
Parent / Guardian #2 - Name
Parent / Guardian #2 - Email
Parent / Guardian #2 - Home Phone
Parent / Guardian #2 - Work Phone
Parent / Guardian #2 - Cell Phone
Emergency Contact (Name, Relationship)
Emergency Contact Phone
Alternate Pickup (Name, Relationship)
Alternate Pickup Phone
Program Information
Please mark areas you would like your child to work on:
Initiating & Maintaining Conversation
Getting Along with Others (Cooperation)
Being a Good Friend
Understanding & Dealing with Feelings (self-esteem)
Handling Social Conflicts
Problem Solving (Collaboration/Compromise)
Are there additional social skills you’d like your child to learn more about? Please list.
Other information you would like us to know:
Has your child previously participated in this program?
Yes
No
If yes, when?
Signature
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.
Initial to omit your name from publicity
Parent / Guardian Signature
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