Community Education - current class catalogs Project Power - Spring 2018

Spring 2018 registration form

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 / caregiver Medical conditions or needs:

Basketball	______ $ 35
Bingo
Apr. 2	______ $ 9
May 31	______ $ 9
Board Games and Snacks	______ $ 9
Bowling with Dirk and Perry Mar. 23	______ $ 25				______ $ 25( bowling & pizza)
	______ $ 15( bowling only)				______ $ 15( bowling only) ______ $ 10( eating only)
Apr. 13	______ $ 25				______ $ 25( bowling & pizza)
	______ $ 15( bowling only)				______ $ 15( bowling only) ______ $ 10( eating only)
May 25	______ $ 25				______ $ 25( bowling & pizza)
	______ $ 15( bowling only)				______ $ 15( bowling only) ______ $ 10( eating only)
Bunny Dirt Cups and Race Cars	______ $ 15
Cinderella, The Musical	______ $ 12				______ $ 5
Cooking 101
Chicken / Twice Baked Potatoes ______ $ 19					______ $ 9( if eating)
Hot Hoagies	______ $ 19				______ $ 9( if eating)
Taco Pizza	______ $ 19				______ $ 9( if eating)
Dinner at Mandarin Buffet 1	______ $ 19				______ $ 15( if eating)
Dinner at Q Fanatic	______ $ 19				______ $ 15( if eating)
Disney on Ice“ Frozen”	______ $ 45				______ $ 35
Dust Devil T-Ball	______ $ 45
Choose shirt size:	___ S	___ M	___ L	___ XL		___ XXL

Fairy Garden	______ $ 29( List number of staff remaining on site ____)
Hairspray Jr., The Musical	______ $ 15	______ $ 9
Karate	______ $ 35
Movie and Pizza	______ $ 19	______ $ 9( if eating)
Movie and Pizza at the Theater Mar. 10	______ $ 19	______ $ 15
May 5	______ $ 19	______ $ 15
Our Feathered Friends	______ $ 19	______ $ 12
Paper, Books and Sculpture	______ $ 15	______ $ 12( Class fee includes lunch and garden tour)
Project Power LIVE Talent Show! Group A	______ $ 35
Group B	______ $ 35
Relaxing Spa Gift for Mom	______ $ 19
Sock Bunny	______ $ 15
Spring Egg Coloring	______ $ 15
Spring Fling	______ $ 29	______ $ 19( if eating) ______ Free( if not eating)
Swimming at Tropics Water Park	______ $ 15	______ Free
Under the Sea	______ $ 15
Watercolor Painting	______ $ 10
Xanadu, The Musical	______ $ 12	______ $ 5

( ONE FORM PER PERSON / THIS FORM MAY BE REPRODUCED)

Please specify information the instructor may need to be aware of( dietary, behavioral or other).

Allergies: Food Medication( specify)

__________________________ 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 Walker Wheelchair

Payment information:

Participant total: Staff / caregiver total: Check Number:

$ ________________ $ ________________

__________________

Make check payable to: Anoka-Hennepin School District

OR Credit card:

Cardholder name:

Visual impairment Staff must remain on site: Yes No

Other:( specify)

___________________________________________

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

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

Spring 2018 registration form

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