Sign-Up Form | Lacrossing Barriers

Name:

Email:

Phone:

Program Dates

Poirier Forum 6:00 - 7:30 PM May 1, 8, 15, 22, 29 June 5, 12, 19, 26 $45 For more information please email scott@lacrossingbarriers.org

Dietary Concerns

Do Medications Need to Be Administered?

Does Attendee Need An Epipen?

Yes

No

Does Attendee Require Mobility Aids or Social Supports?

Will You/the Participant Be Coming Via Transit For Drop-off or Pickup?

Yes

No

Things We Should Know To Help Support During This Program