Community Bridge February - May 2019

COMMUNITY BRIDGE REGISTRATION–PARTICIPANT FORM Name________________________________ Day Phone_________________ Evening Phone ________________ Address___________________________________________________ City_________________ Zip___________ Group Home Name ______________________Contact Person _____________________ Phone ______________ Group Home Email ___________________________________ 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 CBWT1 Behind the Scense at Sea Life (MOA) $25 _______ $__________ CBRR4 April Fools Bingo and Pizza at Fairview $3 _______ $__________ CBSSE1 Valentine Dinner & Comedy Show $20 _______ $__________ CBRR1 Valentine Bingo & Pizza $3 _______ $__________ CBSR13 Let’s Go Bowling $5 _______ $__________ CBSR7A Let’s Go Bowling $5 _______ $__________ CBSR7B Let’s Go Bowling $5 _______ $__________ CBSR7C Let’s Go Bowling $5 _______ $__________ CBSR5A Friday Night Pizza Party $5 _______ $__________ CBSR5B Friday Night Pizza Party $5 _______ $__________ CBSR5C Friday Night Pizza Party $5 _______ $__________ CBSR2 Bingo and Pizza at Cottage Grove $5 _______ $__________ CBNR1 Frolic and Play the Eskimo Way $2 _______ $__________ CBNA2A Express Yourself Tie Dye $10 _______ $__________ CBNA2B Express Yourself Tie Dye $10 _______ $__________ CBNSE4 Grandma’s Best Years $10 _______ $__________ Total Staﬀ Fee for this page $__________

Community Bridge February - May 2019 | Page 11