SUMMER CATALOG RESISTRATION FORM 2018 (JUNE- AUGUST) Deadline: May 1st **Must complete all fields before submittal** Participant Name: Date Submitted: Completed By: Funding Source: Medicaid Waiver Private Pay Case Manager: ($50 deposit attached) Participant Phone: Family/Provider Phone: Participant Email: Family/Provider Email: Preferred Contact before Activities: Mailing Address: Home Address: Alternate Address: Enroll? WEEKLY ACTIVITIES DAY/TIME Pick-Up Location Drop-Off Location Tuesday PM Home Home The League (5pm-8:30pm) Basesite Basesite Wednesday PM Home Home Market & Music (5pm-8:30pm) Basesite Basesite Thursday PM Home Home Paint the Sky (5pm-8:30pm) Basesite Basesite Friday Night Out (FNO) Friday PM Home Home *alternating weeks* (6:30pm-10:30pm) Basesite Basesite Saturday Night Out *1 Saturday per month Saturday PM Home Home (dates listed on (6:30pm-10:30pm) Basesite Basesite calendar)* ****I acknowledge that I have received, read, and understand the information provided in the Out & About Summer 2018 Catalog.**** Participant/ Guardian Signature Date
SUMMER CATALOG RESISTRATION FORM 2018 (JUNE- AUGUST) Deadline: May 1st **Must complete all fields before submittal** Participant Name: Date Submitted: Completed By: Funding Source: Medicaid Waiver Case Manager: Private Pay ($50 deposit attached) Participant Phone: Family/Provider Phone: Participant Email: Family/Provider Email: Preferred Contact before Activities: Mailing Address: Home Address: Alternate Address: Enroll? WEEKLY ACTIVITIES DAY/TIME Pick-Up Location Drop-Off Location The League Tuesday PM (5pm-8:30pm) Home Basesite Home Basesite Market & Music Wednesday PM (5pm-8:30pm) Home Basesite Home Basesite Paint the Sky Thursday PM (5pm-8:30pm) Home Basesite Home Basesite Friday Night Out (FNO) *alternating weeks* Friday PM (6:30pm-10:30pm) Home Basesite Home Basesite Saturday Night Out *1 Saturday per month (dates listed on calendar)* Saturday PM (6:30pm-10:30pm) Home Basesite Home Basesite ****I acknowledge that I have received, read, and understand the information provided in the Out & About Summer 2018 Catalog.**** Participant/ Guardian Signature Date