Springsegueresistration FORM 2018

Spring Segue RESISTRATION FORM 2018 (February – May) *Ages 16-24 Deadline: January 25th

**Must complete all fields before submittal**

Participant Name: Date Submitted: ☐ Private Pay (Deposit will go towards Completed By: Funding Source: payment for services)

*single program ** multi program registration: registration: price of $50 deposit program as deposit Case Manager:

Enroll? SATURDAY DAY/TIME Pick-Up Location Drop-Off Location Medication Administered (PRIVATE PAY) During This Time Boulder Dinner 2/03/2018 ☐ ☐ Home ☐ Home ☐ Theater: Annie (5:30pm- ($90) 10:30pm) ☐ Basesite ☐ Basesite ☐ ☐ Home ☐ Home Movie Day 3/10/2018 ☐ ($40) (3pm-7pm) ☐ Basesite ☐ Basesite

☐ Frozen on Ice 4/07/2018 ☐ Home ☐ Home ☐ ($86) *Time TBD ☐ Basesite ☐ Basesite Butterfly ☐ 5/19/2018 ☐ Home ☐ Home Pavillion ☐ (11am-2pm) ($40) ☐ Basesite ☐ Basesite **All activities are weather dependant and are subject to change

Participant Phone: Family/Provider Phone: Participant Email: Family/Provider Email: Preferred Contact before Activities: Mailing Address: Home Address: Alternate Address:

FORM INSTRUCTIONS  To choose an activity, check the “Select” box.  Transportation: Please select a box for either a pick-up/drop-off at home or at your nearest base site for EACH ACTIVITY (Boulder Base Site: 5421 Western Ave Boulder CLS Site; Longmont Base Site: 1960 Ken Pratt Blvd. Longmont CLS Site; Broomfield Base Site: Good News Community Church 5511 W. 136th Ave. Broomfield; Lafayette Base Site: Imagine! 1665 Coal Creek Drive, Lafayette)

An electronic version of this form will be emailed out to families the week of January 9th. To register online complete this form, save it with the participant’s name and “Spring Segue 2018”, and email it to [email protected] by January 25th, 2018.

You may also mail-in registration to: Out & About ATTN: Emma Goodenow, O&A Catalog Assistant Coordinator 1665 Coal Creek Drive Lafayette, CO 80026

Note: a $5 schedule change fee per event is applied for registration changes requested after the deadline. Any changes must be submitted via a Registration Change Form, also found at the link above.

CANCELLATION AND ILLNESS POLICY  Please notify us of cancellations at least one calendar week prior to a class/event.  Cancelling more than twice for a given class within a quarter may cause the participant to be waitlisted for that class for future months.  Refunds will not be given once the registration deadline has passed.  We reserve the right to suspend services for individuals who cancel without giving sufficient notice.  Participants should NOT attend activities if they have had a fever, diarrhea, or vomiting within 24 hours of the event.  Out & About reserves the right to cancel an event or activity due to safety concerns, weather, or other extenuating circumstances.