2025 Term 1 Registration Form

2025 Term 1 Registration Form
Term: January 13 - April 25
- No sessions: Mon., Jan. 20; Mon., Feb. 17.
Port Angeles

129 W 1st Street

Mondays:

11 am to 3 pm Dance/Movement, Lunch, Rec Club

Dance - Experience different types of movement and music

Rec Club - Games, Activities, Singing, Friends, and Fun

Tuesdays:

11 am to 3 pm Movement, Lunch, Superheroes

Dance - Explore different forms of movement, ie Tai Chi

Superheroes - Exploring and creating your inner Superhero

Wednesdays:

11 am to 3 pm Life Skills, Lunch, Cooking

Skill Building - Work on every day skills and explore community opportunites and create personal emergency safety bags.

Cooking - We will be visiting a farm to learn about growing food and visiting a kitchen to cook.

Fridays:

11 am to 3 pm Stem Club, Lunch, Community Exploration

Stem Club - We will use our skills to build robots, rockets, crystals and many other things.

Community Exploration - Every other week will go out and explore our community with off site activities.

Afternoon Sessions Only

129 W 1st Street, Port Angeles

Tuesdays and Thursdays, please attend both sessions:

3 pm to 5 pm Theatre

Theatre – Live performance from acting to set and costume design

Sequim:

Dungeness Valley Lutheran Church

925 N Sequim Avenue

Thursdays:
11 am to 3 pm Mindfulness and Movement, Lunch, Art

Mindfulness and Movement- Exploration of mindfulness and movements

Art- Explore and work with a different type of medium each month
- Once registrations have been received and class rosters have been created, we will do our best to contact you.
- Participants will receive a 5% discount if the term is paid in full by January 31, 2025..
- If billed fees are not paid by the indicated due date, a 5% late charge will be applied
- Clallam Mosaic will follow State and County Health Officer recommendations to keep participants safe
Port Angeles Monday, Tuesday, Wednesday and Friday 4-hour session fees.
On left: Tuesday and Thursday Theater 2-hour sessions.

On right: Sequim Thursday 4-hour session fees.
Participant Name*

First NameLast Name
Name of Person completing form:

First NameLast Name
Email
example@example.com
Port Angeles Sessions: Which sessions would the participant like to sign up for? (Check all that apply)

Mon,. Dancing and Rec ClubTues , Movement and SuperheroesWed., Skill Building and CookingFri., Community Exploration and Stem ClubTues and Thurs., Theater 3 to 5 pm
Sequim Session:

Thurs., Mindfulness & Movement, and Art
Which town does the participant live in?*

Port AngelesSequimJoyce/Clallam Bay/SeikuForksOther
Due to space limitations in Sequim, we may need to limit the number of participants in that session. Please use the questions below to indicate your preferences.
Which day is your first choice for full day sessions? (pick one)*

Monday, Port AngelesFriday, Port AngelesTuesday, Port AngelesThursday, SequimWednesday, Port Angeles
Please provide any information that will help us with finalizing class rosters:
What is your preferred payment approach? (Choose one option)*

Get billed and pay monthly by the 15th of each monthBill respite monthly. We bill monthly.Pay term in full by January 31, 2025 (5% discount)Pay part with respite and part monthlyPay part with respite and the remaining in full by April 15, 2025 (no discount)Pay with credit card via Square with a 3.5% processing fee
If you chose to have a portion of your payment billed to respite, please indicate what percentage to bill respite:
If you chose to have any portion of your payment billed monthly, please provide the name and address of the person we should send bills to:
If you chose to have any portion of your payment billed to respite, please provide the name of your DDA case manager:
All participants, all annual forms must be submitted at the beginning of the year:
1. 2025 In-Person Intake Form
2. 2025 Health Status Form
3. 2025 Health Liability Release Waiver
4. 2025 In-Person Code of Conduct
5. 2025 Participant Consent Form
All Participants:
1. Term 1 Registration
Should be Empty: