( ONE FORM PER PERSON / THIS

Participant / Staff information : ( No participant substitution without prior notice .)

Name of Participant name : ________________________________ Phone : _______________ Group Home : ______________

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 .

Special Accomodations : � Wheelchair � Allergies ___________________________ � Other _________________________ Staff must remain on site : � Yes � No Photo Release : � Yes � No � ASL Interpreter _________________

Payment is due at the time of registration . Refund and cancellation policy : requests with at least five business days notice from the class start date are eligible for a refund minus a $ 10 processing fee . Refund requests with less than five business days notice from the start of class are not eligible for a refund .

Payment information :

Participant total : $ _________ Staff total : $ _________ UCare member No .: _____________________________

Paper check : Payable to “ Anoka-Hennepin Schools ” All checks processed electonically . Credit card : Cardholder name _____________________________________________ Card No .:_________ - _________ - _________ - ________ Exp . date : ______ / ______

Check out our simple online registration and payment options . ahschools . ce . eleyo . com

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 CALL us at 763-506-1290