Independent School District 622
2520 E 12th Ave
North St. Paul, MN 55109
NON-PROFIT ORG
U.S. POSTAGE
PAID
TWIN CITIES MN
PERMIT NO. 4263
Gladstone Community Education Center
Community Bridge Consortium offi ce
1945 Manton St.
Maplewood, MN 55109
651.748.7252
COMMUNITY BRIDGE REGISTRATION FORM
Name______________________________ Day Phone_______________ Evening Phone____________
Address____________________________________________ City________________ Zip___________
Group Home Name_______________________Contact Person__________________ Phone__________
Group Home E-MAIL________________________________
Class #
Class Name
Participant Fee Staff Attending
# attending Total Staff Fee
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
_____________ __________________________________ $____________ ___________ $___________
Total Participant Fee $ ___________ Total Staff Fee $ __________
__________ Uses a wheelchair. __________ Requires one-to-one assistance?
Staff fee must accompany
registration
List any medical, seizure, behavioral, or other conditions that instructor should be aware of: _______________
______________________________________________________________________________________________
Checks payable to Community Bridge. Mail: Community Bridge, 1945 Manton St, Maplewood MN 55109
or Visa, MasterCard or Discover ______ ______ _____ _____ Exp________Total Charge $________
Signature ___________________________________ Name on Card_______________________________
(Print)