COMMUNITY BRIDGE REGISTRATION–PARTICIPANT FORM
Name________________________________________
Home/Group Home Phone _______________________________
Address______________________________________________________ City_________________________ Zip___________
Group Home Name __________________________ Emergency Contact _______________________ Phone _______________
Group Home Email ___________________________________
Class #
Class Name
Participant Fee # of Staff
Attending
Total Staff Fee
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
UCare Number____________________________________ __________
Total Participant Fee $ ___________
______Uses a Wheelchair/Walker
______Requires one-to-one assistance?
Total Staff Fee $ __________
Staff fee must accompany
registration
List any medical seizure, behavioral, diet or other condition the instructor needs to be aware of:___________________
________________________________________________________________________________________________
Please check if you do not wish your picture to be used for publicity purposes or social media
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_____________________________________
Community Bridge Summer Programming Survey
Please help us plan for summer by completing this survey on behalf of yourself or the people that you bring to Community
Bridge activities.
Circle your answer
Do you typically participate in summer activities off ered by Community Bridge during the summer? Yes No
Do you typically participate in summer activities off ered by other organizations during the summer? Yes No
Do you usually attend a summer camp program? Yes No
Do you usually take a vacation during the summer? Yes No
If Community Bridge did not off er summer activities, would you have another source of social and recreational activities?
Yes
No
Here are my suggestions for activities?_________________________________________________________________
Please tell us what, if anything, can be done to improve your next experience with Community Bridge:______________
________________________________________________________________________________________________
Thank you for taking part in this survey. Community Bridge Advisory Council