Community Education - current class catalogs Project Power - Fall 2017

Fall 2017 registration form (ONE FORM PER PERSON / THIS FORM MAY BE REPRODUCED) Participant/Staff information: (No participant substitution without prior notice.) Participant name: _____________________________________________________________ Phone: _______________________________ Address: __________________________________________________________ City: ________________________ Zip: ______________ Email: ____________________________________________________ (for class confirmation) Birth date: ________ / ______ / __________ REQUIRED - Legal guardian/Emergency contact ( MUST be able to be reached during class time.): ___________________________ __________________ Legal guardian name Phone No. ___________________________ Class/EventParticipantStaff/caregiver Basketball Bingo Sept. 13 Nov. 2 Bowling with Dirk and Perry Oct. 6 Bowling & pizza Bowling only Pizza Nov.17 Bowling & pizza Bowling only Pizza Dec.15 Bowling & pizza Bowling only Pizza Campfire and Hayride Coffee and Pie Cooking 101 Pizza Spaghetti and Salad Cheeseburger Roll Ups Dinner at Denny’s Dinner at KFC Dinner at Pizza Ranch Fall Birdfeeders Fitness Walking Floor Hockey Grand Slam Halloween Dance Holiday Cookie Bake Karate Sep. 11 Nov. 6 Mason Lid Apple Pie Merry Music Makers Movie and Pizza Movie and Subs Moving and Grooving Padelford Riverboat Trip Pancake Mix Gift Jar Pizza and Movie at Theater Oct. 13 Dec. 2 A Christmas Carol at the Guthrie Theater Spooky Appetizers Sunflower Canvas Painting Taco Bar and Games Thanksgiving Dinner Three Spooky Crafts Uno and Floats Vikings Game and Pizza at Davanni’s Wii Games and Donuts Wildlife Field Trip Willy Wonka & the Chocolate Factory Wood Snowman ______ $35 ______ $9 ______ $9 ______ $25 ______ $15 ______ $25 ______ $15 ______ $25 ______ $15 ______ $19 ______ $12 ______ $19 ______ $19 ______ $19 ______ $19 ______ $15 ______ $20 ______ $15 ______ $19 ______ $35 ______ $22 ______ $15 ______ $19 ______ $35 ______ $35 ______ $15 ______ $45 ______ $19 ______ $19 ______ $29 ______ $49 ______ $19 ______ $19 ______ $19 ______ $39 ______ $15 ______ $19 ______ $19 ______ $15 ______ $15 ______ $12 ______ $22 ______ $15 ______ $35 ______ $15 ______ $15 __________________ Emergency contact name ______ $25 ______ $15 ______ $10 ______ $25 ______ $15 ______ $10 ______ $25 ______ $15 ______ $10 ______ $15 ______ $5 (if eating) ______ $9 (if eating) ______ $9 (if eating) ______ $9 (if eating) ______ $15 (if eating) ______ $12 (if eating) ______ $15 (if eating) ______ $15 (if participating) ______ $9 (if eating) ______ $9 (if eating) ______ $39 ______ $15 ______ $15 ______ $29 ______ $9 (if eating) ______ $11 (if eating) ______ $9 (if eating) ______ $15 (if eating) ______ $29 ______ $12 Phone No. Medical conditions or needs: Please specify information to instructor they may need to be aware of (dietary, behavioral or other). Allergies: Food Medication (specify) __________________________ ASL interpreter: Yes No Photo release: Yes No (See p. 16) Seizure: Non-active Active An active seizure disorder MUST have a primary staff or caregiver with participant at all times. Autistic Behavioral Wheelchair Visual impairment Staff must remain on site: Yes Walker No Other: (specify) Payment information: Participant total: $ ________________ Staff/caregiver total: $ ________________ Check Number: __________________ Make check payable to: Anoka-Hennepin School District OR Credit card: Cardholder name: ___________________________________________ Card No.: ____- ____- ____-____ Exp. date: ______ / ______ Mail completed form and payment: Anoka-Hennepin Community Ed. Attn: Project Power 2727 N. Ferry St., Anoka, MN 55303 Or FAX registration to 763-506-1299 Or CALL registration to 763-506-1290

Community Education - current class catalogs Project Power - Fall 2017 | Page 23