Springsegueresistration FORM 2018

Springsegueresistration FORM 2018

SpringSegueRESISTRATION FORM 2018

(February – May)

*Ages 16-24

Deadline:January 25th

**Must complete all fields before submittal**

Participant Name: / Date Submitted:
Completed By: / Funding Source: / ☐Private Pay
(Deposit will go towards payment for services)
Case Manager: / *single program registration: price of program as deposit / ** multi program registration: $50 deposit
Enroll? / SATURDAY (PRIVATE PAY) / DAY/TIME / Pick-Up Location / Drop-Off Location / Medication Administered During This Time
☐ / Boulder Dinner Theater: Annie
($90) / 2/03/2018
(5:30pm-10:30pm) / ☐Home
☐Basesite / ☐Home
☐Basesite / ☐
☐ / Movie Day
($40) / 3/10/2018
(3pm-7pm) / ☐Home
☐Basesite / ☐Home
☐Basesite / ☐
☐ / Frozen on Ice
($86) / 4/07/2018
*Time TBD / ☐Home
☐Basesite / ☐Home
☐Basesite / ☐
☐ / Butterfly Pavillion
($40) / 5/19/2018
(11am-2pm) / ☐Home
☐Basesite / ☐Home
☐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 basesite 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 onlinecomplete this form, save it with the participant’s name and “Spring Segue 2018”, and email it to by January 25th, 2018.

You may also mail-in registration to:

Out & About

ATTN: Emma Goodenow, O&ACatalog 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.
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