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.
Activity
Number
Staff Fee
# of Staff
Total Fee per Activity
CBNSE5
James and the giant Peach $9 _______ $__________
CBNSE6 You’re a Good Man Charlie Brown $10 _______ $__________
CBNSE3 Hausmusik Concert $Free _______ $__________
CBRR4 Bingo and Pizza at Fairview $3 _______ $__________
CBSSE1 Valentine Dinner & Magic Show $20 _______ $__________
CBSC1A Make Toys to Give to Animals Free _______ $__________
CBSC1B Make Toys to Give to Animals Free _______ $__________
$3 _______ $__________
CBRR1 Valentine Bingo & Pizza CBSR4A Let’s Go Bowling $5 _______ $__________
CBSR4B Let’s Go Bowling $5 _______ $__________
CBSR4C Let’s Go Bowling $5 _______ $__________
CBSR4D Let’s Go Bowling $5 _______ $__________
CBSR3A Friday Night Pizza Party $5 _______ $__________
CBSR3B Friday Night Pizza Party $5 _______ $__________
CBSR3C Friday Night Pizza Party $5 _______ $__________
CBSR3D Friday Night Pizza Party $5 _______ $__________
Total Staff Fee for This page
Staff Fees Continued on Back Page
$__________