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