Fall 2021 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 . Emergency contact name Phone No .
Class / Event Participant Staff
Basketball |
___ $ 35 |
Bingo |
September 21 |
___ $ 9 |
|
October 25 |
___ $ 9 |
|
November 23 |
___ $ 9 |
|
December 15 |
___ $ 9 |
|
Dinner at Acapulco |
___ $ 22 |
___ $ 15 ( if eating ) |
Dinner at Pizza Ranch |
___ $ 22 |
___ $ 15 ( if eating ) |
Floor Hockey |
___ $ 35 |
|
Friday Night Bowling September 24 |
___ $ 19 |
___ $ 12 ( if bowling ) |
October 15 |
___ $ 19 |
___ $ 12 ( if bowling ) |
November 12 |
___ $ 19 |
___ $ 12 ( if bowling ) |
December 17 |
___ $ 19 |
___ $ 12 ( if bowling ) |
Grand Slam |
___ $ 19 |
___ $ 15 ( if par .) |
Hayride and Bonfire |
___ $ 19 |
___ $ 15 ( if par . in hayride ) |
Holiday Gnome |
___ $ 19 |
|
Karate September 13 |
___ $ 35 |
|
November 8 |
___ $ 35 |
|
Kiss Cookies and Holiday Treats |
___ $ 19 |
|
Merry Music Makers |
___ $ 55 |
|
Movie and Lunch at Cinema Grill |
___ $ 22 |
___ $ 15 |
Music with Claire |
___ $ 12 |
|
Petey the Puppy Bank |
___ $ 19 |
|
Rootbeer Floats and Uno |
___ $ 15 |
|
Scarecrow Craft |
___ $ 15 |
|
Thanksgiving Dinner |
___ $ 19 |
___ $ 9 ( if eating ) |
The Best Christmas Pageant Ever ___ $ 25 |
___ $ 18 |
The Secret Garden |
___ $ 19 |
___ $ 12 |
Tissue Paper Trees |
___ $ 15 |
|
Watercolor Landscape Art |
___ $ 19 |
|
Did you know ?
Many UCare members can receive up to a $ 15 discount on most Community Education classes . Contact us for further information 763-506-1290 .
Medical conditions or needs : Please specify information to instructor they may need to be aware of ( dietary , behavioral or other ). Primary staff / caregiver must stay , if there is an active seizure disorder .
Seizure Disorder ( active )
Behavioral ASL Interpreter Wheelchair Walker Autistic
Allergies __________________________ Other ____________________________________________ Staff must remain on site : Yes No Photo Release : Yes No
Payment information :
Participant total : $ ________ Staff total : $ ________ UCare member No .: ____________________________ Paper check : Payable to “ Anoka-Hennepin School District ”
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 form to 763-506-1299 or CALL us at 763-506-1290
Check out our new and simple online registration and payment options at www . ahschools . ce . eleyo . com