Community Education - current class catalogs Project Power - Fall 2019

Fall 2019 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 Phone No. Participant 1940 Radio Christmas Carol ______ $35 Basketball ______ $35 Bingo Sept. 10 ______ $9 Oct. 15 ______ $9 Dec. 18 ______ $9 Clay Creations ______ $10 Cooking 101 Appetizers ______ $19 Basic Skills ______ $19 Spaghetti Bread and Garden Salad ______ $19 CPR ______ $12 Dinner at Perkins ______ $19 Dinner at Davanni’s ______ $19 Dinner at Golden Corral ______ $22 Drama Club ______ $39 Elf the Musical ______ $25 Fitness Walking Jackson MS (Mon. and Wed.) ______ $19 Oak View MS (Mon. - Thurs.) ______ $19 Floor Hockey ______ $35 Friday Night Bowling Sept. 13 Bowling & pizza ______ $25 Bowling only ______ $15 Eating only Oct. 18 Bowling & pizza ______ $25 Bowling only ______ $15 Eating only Nov. 22 Bowling & pizza ______ $25 Bowling only ______ $15 Eating only Dec. 13 Bowling & pizza ______ $25 Bowling only ______ $15 Eating only Halloween Dance Party ______ $19 Hayride and Bonfire ______ $19 Holiday Cookies ______ $22 James and the Giant Peach Musical ______ $19 Joy Wreath ______ $19 Karate Sept. 9 - Oct. 21 ______ $35 Nov. 4 - Dec. 16 ______ $35 Light Tour ______ $25 Light Up Sign at DIY Boardwalk ______ $35 Merry Music Makers ______ $45 Movie and Lunch at Cinema Grill ______ $19 Movie and Pizza at Oak View MS ______ $19 Movie and Pizza at the Theater ______ $19 Moving and Grooving with Abby ______ $35 Music and More with Claire ______ $10 Peter and the Starcatcher ______ $12 Photo Blocks Holiday Gift ______ $19 Pumpkin Pie and Coloring ______ $15 Sensory Friendly Performance ______ $12 Seizure Smart Training ______ FREE Riverboat Cruise ______ $45 Lunch choice: Turkey Sandwich Vegetarian Self Defense ______ $15 Scarecrow Pots ______ $19 Thanksgiving Dinner ______ $15 Emergency contact name Staff/caregiver ______ $29 ______ $9 (if eating) ______ $9 (if eating) ______ $9 (if eating) ______ $5 (if participating) ______ $15 (if eating) ______ $15 (if eating) ______ $19 (if eating) ______ $19 ______ $25 ______ $15 ______ $10 ______ $25 ______ $15 ______ $10 ______ $25 ______ $15 ______ $10 ______ $25 ______ $15 ______ $10 ______ $14 ______ $15 (if participating in hayride) ______ $15 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. 21) Seizure: Active Non-active An active seizure disorder MUST have a primary staff or caregiver with participant at all times. _____________________________________ Autistic Behavioral Walker Wheelchair Visual impairment Staff must remain on site: Yes No Other: (specify) _____________________________________ _____________________________________ _____________________________________ Payment information: Participant total: $ ______________ Staff/caregiver total: $ ______________ Check Number: _______________ Make check payable to: Anoka-Hennepin School District OR Credit card: ______ $19 Cardholder name: ______ $15 ______ $9 (if eating) ______ $15 ______ $9 ______ $9 ______ FREE ______ $39 Gluten Free ______ $9 (if eating) ______________________________________ 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 22

Community Education - current class catalogs Project Power - Fall 2019 | Page 23