Community Education - current class catalogs Project Power - Spring 2015

Spring 2015 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: ________ / ______ / __________ Month Day Year REQUIRED - Legal guardian/Emergency contact: Guardian name: ________________________________________________ Phone: ____________________________ Emergency contact: ____________________________________________ Phone: ____________________________ (Emergency contact must be able to be reached during class time, not a voicemail or machine.) spOrT OuT & OUT & Music & & SPORTS & MUSIC s& abOuT ABOUT TheaTre EXERCISE THEATRE LAUGH & LEARN COOKING & DINING ARTS & CRAFTS Bubble Paint T-Shirt Participant ______ $19 T-shirt size needed ___ S ___ M Cookie Sheet Magnet Board Participant ______ $19 Egg Coloring Participant ______ $9 Mother’s Day Spa Soap Participant ______ $19 Cooking 101-Salisbury Steak Participant ______ $15 Cooking 101-Stir Fry Participant ______ $15 Cupcake Indulgence Participant ______ $15 Dinner at Panda Garden Buffet Participant ______ $15 Dinner at Pizza Ranch Participant ______ $15 Bingo Participant ______ $9 Karaoke Participant ______ $11 Life Skills-Banking 101 Participant ______ $15 Science of Magic Participant ______ $15 Seizure Recognition & Response Participant ______ Free Uno & Root Beer Floats Participant ______ $9 Aladdin Jr. Musical Participant ______ $15 Bunnicula At Lyric Arts Participant ______ $19 Choir Concert Participant ______ $9 Steps of Hope Walk For Autism Choir Participant ______ $9 Cinema Grill Participant ______ $19 Sky Zone Trampoline Park Participant ______ $19 Spring Fling Dinner & Dance Participant ______ $29 ___ L ___ XL ___XXL Staff ______ Free Staff ______ Free Staff ______ $15 Staff ______ $15 Participant total $ ______________ Check No.: _____________ OR Credit card: Make check payable to: Anoka-Hennepin School District Credit card No.: - Primary caregiver must stay, if there is an active seizure disorder. Allergies: Food Medication (Specify) __________________________ ASL interpreter: Yes No Photo release: Yes No (See page 16) Seizure: Staff ______ $15 Staff ______ Free Active Non-active Autistic Behavioral Walker Wheelchair Visual impairment Staff ______ $9 Staff ______ $15 Staff ______ Free Staff must remain on site: Yes No Other: (specify) ______________________ Staff ______ Free Staff ______ $19 Staff ______ $19 Staff ______ $19 (If not eating) ______ Free Syruping & Pancake Breakfast Participant ______ $19 Staff ______ $15 Basketball Participant ______ $25 Bowling & Pizza with Dirk & Perry Participant ______ $19 Staff ______ $19 (bowling only) ______ $9 (pizza only) ______ $9 Dust Devil T-Ball Participant ______ $35 T-shirt size needed ___ S ___ M ___ L ___ XL ___XXL Fitness Dance Participant ______ $29 Karate Participant ______ $29 Payment Information: Medical conditions or personal needs: Staff total $ ________________ Mail completed form and payment to: Project Power Attn: Julie Johnson 2727 N. Ferry St. Anoka, MN 55303 Or FAX the form to 763-506-1299 Or CONTACT Julie at 763-506-1290 This form is also available in digital form online at www.discovercommunityed.com 17 Cardholder name:___________________________________ - - Exp. date: ________ / _______

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