2024 CERAMICS 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!
 
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Correo *
OPWDD Individuals First Name *
OPWDD Individuals Last Name *
Class type (art, yoga, fitness, etc) *
Date of Class and time *
Fiscal Intermediary Agency Name *
Fiscal Intermediary Contact Name *
Fiscal Intermediary Contact Email Address *
Authorized signer (name) *
I understand that my initials below as parent/guardian/approved agent is legally binding as my printed signature *
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