Community Bridge October 2019 - January 2020 | 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 $5 _______ $__________ CBRR4 New Year’s Pizza and Bingo $5 _______ $__________ CBSR2A Friday Night Pizza Party $5 _______ $__________ CBSR2B Friday Night Pizza Party $5 _______ $__________ CBSR3 Bingo and Pizza - Cottage Grove $5 _______ $__________ $30 _______ $__________ $5 _______ $__________ CBNT1 Fall Riverboat Cruise CBSR1A Let’s Go Bowling CBSR1B Let’s Go Bowling $5 _______ $__________ CBSR1C Let’s Go Bowling $5 _______ $__________ $__________ CBNT2 Craft Soda Brewery Tour $15 _______ CBSR4 Friday Night Fun With Friends $ 5 _______ $__________ CBSSE3 The Addams Family $10 _______ $__________ CBNSE3 Monty Python’s Spamalot $10 _______ $__________ CBSSE1 Hayride & Tour at Afton Apple Orchard $12 _______ $__________ CBNR3 Sunfish Lake Park Adventure $5 _______ $__________ Total Staff Fee $__________ Register online with a Visa, Mastercard or Discover Card at www.isd622.ce.eleyo.com 11