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
Register online at isd622 . ce . eleyo . com COMMUNITY BRIDGE REGISTRATION FORM
Name _________________________________________________ Home / Group Home Phone _____________________________ Address ____________________________________________________ City ____________________________ Zip ___________ Group Home Name _____________________________ Emergency Contact ____________________ Phone _________________ Group Home Email ______________________________________ o Uses a wheelchair o 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 $___________ Checks payable to : Community Bridge Mail : Community Bridge , 1945 Manton St , Maplewood , MN 55109
Staff fee must accompany registration
Mailed checks will be handled as a one-time electronic fund transfer or draft . or Visa , MasterCard or Discover _________ _________ _________ _________ Exp ____/____ Total Charge $___________ Signature _________________________________________ Print Name on Card _____________________________________