SPARK Website Intake

SPARK Intake and Agreement

Women's Centers of Ohio
Fill out the form to join our live Zoom classes—interactive, supportive, and all from the comfort of your own home!

** Earn points for every class you complete ** Spend your points on baby essentials
Legal Name*

First NameLast Name
Email*
example@example.com
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary language spoken at home: (Our online ZOOM classes are in English)*
Have you been reported to Child Protective Services?*
Was there a substantiated case?*
Is the case still open?*
How many children under the age of 4 do you have? If you are currently pregnant please count that child as one child*

Child 1 Info:*

Rows	Child's Name	Child's Age	Lives with you?
Child 3

Child 2 Info:*

Rows	Child's Name	Child's Age	Lives with you?
Child 2

Child 3 Info:*

Rows	Child's Name	Child's Age	Lives with you?
Child 3

Child 4 Info:*

Rows	Child's Name	Child's Age	Lives with you?
Child 4

Child 5 Info:*

Rows	Child's Name	Child's Age	Lives with you?
Child 5

Child 6 Info:*

Rows	Child's Name	Child's Age	Lives with you?
Child 6

SPARK Participation Agreement

When you sign up for a class you are agreeing to:
- Consent to Communication
  - By participating in our classes, you agree to receive communication from us via phone or text regarding your classes and program updates.
- Be Present and Engaged
  - Please attend online and actively participate by unmuting yourself or using the chat feature when needed.
- Complete All Lessons
  - To receive points, you must complete all lessons in your series.
- Keep Your Camera On
  - Your camera must remain on and focused on you during the class in order to receive credit.
- Give Yourself Grace
  - You’re learning—and sometimes learning something new! Show yourself empathy throughout the process.
- Create a Respectful Space
  - Help us keep our online environment safe, supportive, and free from judgment—for yourself and others.
If you have an open Child Protective Services case, please let our Education staff know. We’re here to support you and can connect you with helpful resources and organizations where you can take classes that may be a good fit for you. We want to make sure you get the most out of your experience! Just a quick reminder: if any information you provide to us is inaccurate, you won’t be able to receive credit for the class. Additionally, we don’t offer certificates for our classes, but we’re always here to assist and guide you in the best direction
I have read and agree to the terms of the SPARK Program at the Women's Centers.
Should be Empty:

SPARK Intake and Agreement

Fill out the form to join our live Zoom classes—interactive, supportive, and all from the comfort of your own home!