Reading & Writing Archives

Online Course Scholarship Application

Spark 101 Registration

1 Student Information

2 Support Person Information

3 Payment Information

Step 1: Student Information
Student Name*
First Name Last Name
Student Email*
We'll use this to register you for the Celebrate EDU site
Student Cell Phone Number
Optional. We'll use this for text reminders, if you want them!
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/friend 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

Spark 101
Spark 101 Price: $75.00
Price: $75.00
Part 3: Payment Information
Billing Address*
Street Address Address Line 2 City State ZIP Code
Coupon Code
If you have a coupon code, enter it here and click "apply". For a limited time we are offering coupon code COVID for $10 off the registration price!
Credit Card*

Card Details

Cardholder Name
Payments are securely processed through Stripe. Your card information is protected with SSL encryption and SCA (Strong Customer Authentication) and is not stored on our servers.
Total
$0.00
Comments
This field is for validation purposes and should be left unchanged.

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Your Name*
First Last
Your Email Address*
Don't have one? Click here to take our Create an Email Course
Your Cell Phone Number*
We will use this for text reminders
I am a...*
- Self-Advocate / Person with a disability
- Family Member
- Service Provider
We promise we will not share your contact information with anyone. We will only use it for messages about this course and class reminders.

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