Spark 101 Billing Sign Up

1Student Information

2Support Person Information

3Payment Information

Step 1: Student Information
Student Name*
First Name Last Name
Student Email*
Required for access to the course
Student Cell Phone Number
Optional. We'll use this for text reminders, if you want them!
Student Location*
City State
Choose Your Preferred Start Date for Spark 101*
- August 30
- September 13
- September 27
Is the person filling this out the student who is participating in Spark 101?*
- Yes, I am the student
- No, I am a family member/support person of the student

Part 2: Support Person
The support of friends & family is really important to us. Please share the information of the support person that will be assisting the student through Spark 101:
The support of friends & family is really important! We ask that Spark 101 students have a support person that will be available throughout the course. Please share their information with us:
Support Person Name*
First Name Last Name
Support Person Email Address*
Support Person Cell Phone Number
Optional. We will only use this if we are having trouble getting in contact with the student.
Support Person relationship to the student*
- Family Member
- Friend
- Staff
- Other

Part 3: Billing Information
Name of Organization Paying for Spark 101*
Organization Contact Person*
First Last
Contact Person Email*
Contact Person Phone*
Organization Address*
Street Address Address Line 2 City State ZIP Code
Please indicate the source of payment you are using*
- Funding provided by a service provider agency
- Funding authorized from a government agency
- I am using self-directed funds
Important: You will be registered for Spark 101 after confirmation of your payment source.
Comments
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