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 office 1945 Manton St . Maplewood , MN 55109 651.748.7250
COMMUNITY BRIDGE REGISTRATION - PARTICIPANT FORM Name ______________________________________ Home / Group Home Phone _____________________________ Address ________________________________________________ City _____________________ Zip ___________ Group Home Name _______________________ Emergency Contact ____________________ Phone ______________ Group Home Email ________________________________ Uses a wheelchair Requires one-to-one assistance
Medical , seizure , behavioral or other conditions instructor should be aware of : ________________________________ ______________________________________________________________________________________________
Staff Attending Class # Class Name Participant Fee # attending Total Staff Fee
_____________ __________________________________ $____________ ___________ $___________ _____________ __________________________________ $____________ ___________ $___________ _____________ __________________________________ $____________ ___________ $___________ _____________ __________________________________ $____________ ___________ $___________ UCare Number _____________________ Total Participant Fee $ ___________
Total Staff Fee $___________
Staff fee must accompany registration
Checks payable to : Community Bridge Mail : Community Bridge , 1945 Manton St , Maplewood , MN 55109 or Visa , MasterCard or Discover ______ ______ _____ _____ Exp ________ Total Charge $________ Signature ___________________________________ Print Name on Card _______________________________
We are using a “ Register Now Pay Later ” procedure for all classes . Payment information is required at the time of registration , but your credit / debit card or checking account will not be charged until 3 days prior to the class start date . Mailed checks will be handled as a one-time electronic fund transfer or draft . You will be notified if classes are cancelled .