Fall Adult Registration

Fall 2019 Adult Registration Form

Participant First Name:(required)
Participant Middle Initial:
Participant Last Name:(required)
Participant Birthdate:(required)
Will anyone accompany this participant during activities?
YesNo
If yes, please explain:
Will a Service Animal accompany this participant during activities?
YesNo
If yes, please explain:
Participant Phone: (If Applicable)
Contact:
ParentGuardianSelf
Group Home StaffOther
Group Home Name:
Contact First Name:(required)
Contact Last Name:(required)
Contact Address:(required)
Contact City:(required)
Contact Zip Code:(required)
Phone1:(required)
Phone 2:
Email:(valid email required)
Prefer Contact by:
Email
Phone
Party Responsible for Payment:
AgencyGuardianParent
Self Pay
Name of Agency:
Consultant Name:
Consultant Phone Number:
Consultant Email:
Christmas Party December 15th 12 to 3
Free
Adult Swim:
$120.00 7 sessions "New"
Dance Club:
$55.00 7 sessions
Admirals Game:
$150.00 for 3 Games
Bowling Club:
Bowling League $90.00 7 sessions
Leisure Bowling $70.00 7 sessions
Fund Raising Club:
Free
Cooking Class:
$110.00 7 sessions
Movies
$85.00 for 5 sessions
Adult Respite:
August 23, 2019 $295.00
September 20, 2019 $295.00
October 18, 2019 $295.00
November 15, 2019 $295.00
December 13, 2019 $295.00
Note: 48 Hr CANCELLATION is required for all respites otherwise you will be responsible for payment
Parent/Self Pay Total $
Agency Total $
Comments:
Check here to have a copy of this Fall Registration forwarded to the email you provided above.

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