Community Bridge April-June 2017 | Page 11

COMMUNITY BRIDGE REGISTRATION - PARTICIPANT FORM Name ________________________________ Day Phone _______________ Evening Phone ____________ Address ____________________________________________ City _________________ Zip ___________ Group Home Name ___________________ Contact Person _____________________ Phone ___________ Group Home E-Mail ___________________________________ Class # Class Name Location Fee

Checks payable to Community Bridge . Mail : Community Bridge 1945 Manton St . Maplewood MN 55109 or charge Visa / MasterCard ________ _________ ________ ________ Exp ____________ Total Charge $__________

Signature _____________________________________ Name on Card ______________________________________ For questions or to register by phone call the Community Bridge office at 651-748-7232 STAFF REGISTRATION FORM - When staff fee is required .

This portion of the registration form must be completed when there is a fee charged for staff to attend an activity with the participant ( s ). The staff is part of the total count in such activities .

Group Home Name and Address

# of Staff Attending

Total Staff Fee :

Staff Fee ( s ) per Activity

$ $ $ $ $ $ $ $ $ $ $

$ $ _________