Community Bridge October 2018 - January 2019 | 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 ___________ ________________________________ ____________________ ___________ ___________ ________________________________ ____________________ ___________ ___________ ________________________________ ____________________ ___________ ___________ ________________________________ ____________________ ___________ ___________ ________________________________ ____________________ ___________ 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. Number Activity Staff Fee # of Staff Total Fee per Activity CBRR1 Bingo and Pizza Costume Party $3 _______ $__________ CBSR2A Friday Night Pizza Party $5 _______ $__________ CBSR2B Friday Night Pizza Party $5 _______ $__________ CBSR2C Friday Night Pizza Party $5 _______ $__________ CBSR5 Bingo and Pizza - Cottage Grove $5 _______ $__________ Free _______ $__________ $5 _______ $__________ CBSV1 Feed My Starving Children CBSR4A Let’s Go Bowling CBSR4B Let’s Go Bowling $5 _______ $__________ CBSR4C Let’s Go Bowling $5 _______ $__________ CBSSE1 Les Miserables - High School Musical $6 _______ $__________ $ 12 _______ $__________ CBNSE5 Bell Museum & Planetarium CBNSE3 The Addams Family $10 _______ $__________ CBNSE2 Annie $10 _______ $__________ CBNSE6 Ramsey County Fright Farm CBWT1 Elko Speedway CBWT2 PINZ (Staff Pizza) $12 _______ $__________ $30 _______ $__________ $3 _______ $__________ CBWT3 It’s A Wonderful Life $25 _______ $__________ Total Staff Fee Register online with a Visa, Mastercard or Discover Card at www.isd622.ce.eleyo.com $__________ 11