Spring 2023 registration form

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

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 .

Class / Event Participant Staff

Absolutely Elvis	____ $ 15	____ $ 15
Bingo March 22	____ $ 11
April 26	____ $ 11
May 10	____ $ 11
Breakfast for Dinner	____ $ 22	____ $ 22 ( if eating )

Cherry Bread	____ $ 19
Dandelion Painting	____ $ 22
Dinner at Davanni ’ s	____ $ 22	____ $ 22 ( if eating )

Dust Devil T-Ball	____ $ 49
Egg Wreath	____ $ 22
Feeling Safe & Independent at Home	____ $ 35
Friday Night Bowling March 17	____ $ 21	____ $ 21 ( if bowling )

April 14	____ $ 21	____ $ 21 ( if bowling )
May 19	____ $ 21	____ $ 21 ( if bowling )

Grand Slam	____ $ 22	____ $ 22 ( if participating )
Hip Hop Dance	____ $ 9
Karate	____ $ 39
Koala Painting	____ $ 22
May Day Baskets	____ $ 12
Mother ’ s Day Flower Pots	____ $ 19
Pasta Night	____ $ 19
Project Power Bowling Invitational	____ $ 22
Puzzles , Gams & Cookies	____ $ 15	____ $ 9 ( if eating )

Shamrock Sundaes & Movie	____ $ 15	____ $ 9 ( if eating )
Special Olympics Basketball	____ $ 45
Spongebob Musical	____ $ 22	____ $ 22
Spring Dance !	____ $ 15	____ $ 9 ( if eating )

Stained Glass Art	____ $ 22
String Nail Art	____ $ 22
Taco Night	____ $ 19
Tuesday Bowling League	____ $ 59
Zumba Moving & Grooving	____ $ 15

• 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 . Combines individuals with intellectual disabilities and those without intellectual disabilities to participate in classes and activities together !

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 Photo Release : � Yes

Payment information :

� No

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

Use your credit or donate to Community Ed .: $ _______ Paper check : Payable to “ Anoka-Hennepin School District ” All checks processed electonically . 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 simple online registration and payment options .

ahschools . ce . eleyo . com

Community Education - current class catalogs Project Power - Spring 2023 | Page 7

Spring 2023 registration form