Community Education - current class catalogs Project Power - Fall 2018

Fall 2018 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 Class / Event “A Charlie Brown Christmas” Animal Trinket Dish Autumn Leaves Art Basketball Bingo Sept. 26 Nov. 20 Bowling with Dirk and Perry Sept. 14 Bowling & pizza Bowling only Eating only Nov. 9 Bowling & pizza Bowling only Eating only Dec. 7 Bowling & pizza Bowling only Eating only Can Can Wonderland Canvas Painting Party Cirque du Soleil-Corteo Como Zoo Visit Cooking 101 Burritos Chicken Cordon Bleu Casserole Chicken Parmesan and Pasta Dinner at Perkins Dinner at Pizza Ranch Drama Club “Elf Jr.,” the Musical Fall Kick-off Party Fitness Walking JMS/OVMS Floor Hockey Glass Painting Halloween Dance Party Hayride and Bonfire Karate Sept. 10 Nov. 5 Layers of Winter Art Merry Music Makers Movie and Dinner Movie at the Theater Old Fashioned Party Pool Party “Prancer” at Lyric Arts Sea Life Behind-The-Scenes-Tour Sugar Cookies Thanksgiving Dinner and Pie Turkey Painting Phone No. Participant _______ $12 _______ $22 _______ $10 _______ $35 ___________________________ Staff / Caregiver _______ $9 _______ $25 _______ $15 _______ $25 _______ $15 _______ $15 _______ $19 _______ $49 _______ $9 _______ $19 _______ $19 _______ $19 _______ $19 _______ $19 _______ $39 _______ $15 _______ Free _______ $19 _______ $35 _______ $15 _______ $15 _______ $19 _______ $35 _______ $35 _______ $10 _______ $45 _______ $19 _______ $19 _______ $15 _______ $15 _______ $35 _______ $25 _______ $15 _______ $15 _______ $15 Phone No. Medical conditions or needs: Please specify information the instructor may need to be aware of (dietary, behavioral or other). Allergies: _______ $9 _______ $9 _______ $25 _______ $15 __________________ Emergency contact name Medication (specify) Food __________________________ _______ $25 _______ $15 _______ $10 _______ $25 _______ $15 _______ $10 _______ $25 _______ $15 _______ $10 _______ $19 (if participating) _______ Free (bus only) _______ $15 (if painting) _______ $45 _______ $9 (if eating) _______ $9 (if eating) _______ $9 (if eating) _______ $15 (if eating) _______ $15 (if eating) _______ $12 ASL interpreter: Yes No Photo release: Yes No (See p. 16) Seizure: Active Non-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: _______ $15 (if participating in hayride) Cardholder name: ___________________________________________ Card No.: _______ $9 (if eating) _______ $15 _______ Free _______ $29 _______ $15 _______ $9 (if eating) ____- ____- ____-____ 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 22

Community Education - current class catalogs Project Power - Fall 2018 | Page 23