Community Bridge October 2017 - January 2018 | Page 11

Name ________________________________ Day Phone _________________ Evening Phone ________________ Address ___________________________________________________ City _________________ Zip ___________ Group Home Name ______________________ Contact Person _____________________ Phone ______________ Group Home E-Mail ___________________________________

Number

COMMUNITY BRIDGE REGISTRATION- PARTICIPANT FORM

Wheelchair / Mobility Access _______________ Requires one-to-one assistance? ______________

List any medical, seizure, behavioral, diet or other condition the instructor needs to be aware of: ____________ _______________________________________________________________________________________________

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 ______________________________________

STAFF REGISTRATION FORM- When staff fee is required. Activity

Staff Fee # of Staff Total Fee per Activity