2023 SPARK Summer Program Referral Form

2023 SPARK Summer Program Referral Form
Today's Date*

MonthDayYear
Date
I am filling out this form for*

MyselfSomeone else
What is your relation to the youth/role in the community?

Parent/guardianOther relativeSchool staffCommunity memberOther

Youth Information

Please complete the following information about yourself
Youth Name*

First NameLast Name
Pronouns
(ex. she/her, he/him, they/them, etc.)
Youth Phone Number*
Please enter a valid phone number.
Youth Email
example@example.com
Youth preferred method of communication (please choose all that apply)

Voice CallText MessageEmailOther
Date of Birth*

MonthDayYear
Date
Current grade (2022-23 school year)*
What school do you attend?*
Address*

Street Address

Apt/Suite number (if applicable)

CityState

Zip Code
Did you participate in SPARK Summer last year (2022)?*

YesNo

Parent/Guardian Information

Please complete the information below
Parent/Guardian Name*

First NameLast Name
Parent/Guardian pronouns
(she/her, he/him, they/them, etc.)
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Parent/Guardian preferred method of communication (please choose all that apply)

Voice CallText MessageEmailOther

Youth Information

Please complete the following information for the youth you are referring. **Please note: priority will be given to new SPARK Summer participants. Remaining spaces after May 22nd will be offered to returners on a first-come, first-serve basis.
Name of youth you are referring*

First NameLast Name
Youth's pronouns
(she/her, he/him, they/them, etc.)
Youth's Date of Birth*

MonthDayYear
Date
Youth Current Grade Level*
Youth's School *
Youth Phone Number*
Please enter a valid phone number.
Youth's Email
example@example.com
Youth's preferred method of communication

Voice CallText messageEmailOther
Youth's Address*

Street Address

Apt./Suite # (if applicable)

CityState

Zip Code
Did this youth participate in SPARK Summer last year (2022)?*

YesNo

	Top Choice	2nd Choice	3rd Choice	4th Choice	This time doesn't work for me
June AM Session (June 12-28) Mon.-Wed. 9a-12p
June PM Session (June 12-28) Mon.-Wed. 1:30p-4:30p
July AM Session (July 10-26) Mon.-Wed. 9a-12p
July PM Session (July 10-26) Mon.-Wed. 1:30p-4:30p

Youth Information