Somers | Kids Express

Participant Information

Name*

Birthdate (mm/dd/yy)*

Age*

Gender*

Male
Female

School*

Grade*

Teacher*

Bus # / Route*

Student's Address*

Street Address City 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