Community Education - current class catalogs Project Power - Spring 2020 | Page 23

Spring 2020 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
Anastasia Musical and More
______ $15
Anime and Gaming Club
______ $35
Basketball
______ $35
Bingo

Mar. 24
______ $9

Apr. 7
______ $9

May 26
______ $9
Candybar Bars
______ $15
Cereal Box Notebooks
and Flower Pens ______ $15
Comic-Con
______ $29
Cooking 101

Apr. 28: Chicken Fettuccine Alfredo ______ $19

May 14: Lasagna Roll Ups ______ $19
Dinner at Clive’s Roadhouse ______ $21
Dinner at Denny’s ______ $19
Dinner at Pizza Ranch ______ $19
Disney on Ice-Road Trip Adventure ______ $49
Dream Catchers for Mom ______ $19
Dust Devil T-Ball (Choose shirt size) ______ $45
Feed My Starving Children ______ $5
Friday Night Bowling

Mar. 27
(bowling & pizza) ______ $25

(eating only) ______ $10

(bowling only) ______ $15

Apr. 17
(bowling & pizza) ______ $25

(eating only) ______ $10

(bowling only) ______ $15

May 8
(bowling & pizza) ______ $25

(eating only) ______ $10

(bowling only) ______ $15
Girls Night Out - Shop and Dinner ______ $9
Guys Night Out - Dinner and Trivia ______ $9
Joseph and the Amazing Tech.
Dreamcoat Musical ______ $25
Hairspray Musical ______ $9
Karate ______ $35
Movie and Pizza at the Theater ______ $19
Pillowcase Bag ______ $15
Project Power LIVE
Group A ______ $35

Group B ______ $35
Rock Climbing and Trampoline
Tricks at Urban Air ______ $29
Special Olympics
Competitive Basketball (Choose shirt size) ______ $55
Spring Fling Dinner and Dance ______ $29

Swimming at the Tropics ______ $15
Taco Bar and a Movie ______ $19
The Little Mermaid Musical ______ $15
Emergency contact name
Staff
Medical conditions or needs:
______ $15
______ $19
______ $9 (if eating)
______ $9 (if eating)
______ $17 (if eating)
______ $15 (if eating)
______ $15 (if eating)
______ $39
S M L
______ Free
Phone No.
XL
XXL
______ $25
______ $10
______ $15
______ $25
______ $10
______ $15
______ $25
______ $10
______ $15
______ $15
______ $5
______ $15
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:
$ ______________
UCare Member No.: ____________________
Check Number:
_______________
Make check payable to:
Anoka-Hennepin School District
OR Credit card:
Cardholder name:
______________________________________
Card No.:_______-_______-_______-______
Exp. date: ______ / ______
______ $9 (if participating)
S M L XL XXL
______ $19 (if eating)
______ Free (if not eating)
______ Free
______ $9 (if eating)
______ $9
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
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