Special Needs Event Registration Form

                        Event will be held on Sunday July 17, 2011

                     Starting at 11:00 A.M.

                  At Triangle

                    420 Pearl Street, Malden, MA  02148

               RAIN OR SHINE

Please complete this form and return no later than  July 1, 2011.

Please list names on back of this form if more than one client will be attending.

Name of client attending:_______________________________

Total number attending:________________________________

Address:______________________________________________

City/Town:________________State:___________Zip:________

Name of School or Group Affiliated with:__________________

I hereby release the Pioneers from any/all liability while participating at the event.

Signature:_____________________________Date:___________

Return completed form to:             

Caroline Cook,  18 Sargent Street ,  Malden, MA 02148

If picture taking is allowed, please indicate below:

                   _______Yes              _______No

If you need assistance or additional information please contact:

Caroline Cook at 781-322-2165.  Thank You.

Note:  It is nice to hear from our satisfied “customers”.  If you feel, our assistance was beneficial, please let us know by dropping us a line or two. 

Please let us know if we can improve the services we provide. We look forward to hearing from you.