Dragon Dates-Yoga Night

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Monday, April 22, 2019
Elm Park United Methodist Church
401 Chestnut Street
Oneonta, NY 13820
Please note: This event is for individuals with OPWDD eligibility living in the family home in Broome, Chenango, Delaware, Otsego, Tioga and Tompkins Counties. Parents/caregivers must attend. Siblings are welcome and encouraged to attend.

First and Last name of individual with OPWDD eligibility. *

Parent(s) or Guardian(s) First and Last name. *

Best Phone Number to Contact You Incase of Any Changes. *

Email Address *

TABS# of individual with OPWDD eligibility. If you are unsure of the TABS# please contact your MSC provider. *

Name of individual's Care Manager (formerly known as MSCs) *

Does this individual have Self-Directed Services? *

Yes

Mailing Address *

County of Residency *

Best contact phone number to reach you incase of any changes. *

Total number of individuals attending. *

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