JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
2024 ZUMBA -- Self-Direct for Community Class
RSVP for class and authorization to direct bill my OPWDD FI for community class at Bring on the Spectrum., Please complete for each class separately and make sure to have the class date. THANKS!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
OPWDD Individuals First Name
*
Your answer
OPWDD Individuals Last Name
*
Your answer
Class type (art, yoga, fitness, etc)
*
Your answer
Date of Class
*
Your answer
Fiscal Intermediary Agency Name
*
Your answer
Fiscal Intermediary Contact Name
*
Your answer
Fiscal Intermediary Contact Email Address
*
Your answer
Authorized signer (name)
*
Your answer
I understand that my initials below as parent/guardian/approved agent is legally binding as my printed signature
*
Your answer
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
