Community Education - current class catalogs Project Power - Spring/Summer 2019

Winter 2019 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 All About Dogs ______ $9 Basketball ______ $35 Bingo Apr. 2 ______ $9 May 28 ______ $9 Clay Pot Birdbath ______ $19 Coffee Cup Candle ______ $15 Cooking 101 Burgers and Fries ______ $19 Sheet Pan Chicken ______ $19 Taco Casserole and Cinnamon Crips ______ $19 Dinner at Clive’s ______ $19 Dinner at KFC ______ $15 Dinner at Mandarin Buffet 1 ______ $19 Dust Devil T-Ball ______ $45 Choose shirt size: _ __ S ___ M ___ L ___ XL Easter Bunny Candy Cups ______ $15 Feel the Beat ______ $10 FootGolf ______ $15 Friday Night Bowling Mar. 22 Bowling & pizza ______ $25 Bowling only ______ $15 Eating only Apr. 12 Bowling & pizza ______ $25 Bowling only ______ $15 Eating only May 17 Bowling & pizza ______ $25 Bowling only ______ $15 Eating only Grand Slam ______ $19 “Hillbilly Hayride,” the Musical ______ $15 Karaoke and Ice Cream Sundae Party ______ $11 Karate ______ $35 Luminary Sculptures ______ $10 “Mary Poppins, JR.,” the Musical ______ $12 Mickey’s Search Party at Disney on Ice ______ $45 Movie and Pizza at the Theater ______ $19 Movie and Subs ______ $19 Project Power LIVE Group A (5:30-7pm) ______ $35 Group B (7-8:30pm) ______ $35 Spring Confetti Bars ______ $12 Spring Fling Dinner and Dance ______ $29 Suncatchers for Mom ______ $15 Swimming at Tropics Waterpark ______ $15 Taco Bar and Games ______ $19 Emergency contact name Staff/caregiver ______ $9 (if eating) ______ $9 (if eating) ______ $9 (if eating) ______ $15 (if eating) ______ $12 (if eating) ______ $15 (if eating) ___ XXL ______ $7 (if playing) ______ $25 ______ $15 ______ $10 ______ $25 ______ $15 ______ $10 ______ $25 ______ $15 ______ $10 ______ $15 (if participating) ______ $12 Phone No. Medical conditions or needs: 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. 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 Visual impairment Staff must remain on site: Yes No Other: (specify) _____________________________________ _____________________________________ _____________________________________ Payment information: Participant total: $ ______________ Staff/caregiver total: $ ______________ Check Number: _______________ Make check payable to: Anoka-Hennepin School District OR Credit card: ______ $9 ______ $39 ______ $15 ______ $9 (if eating) Cardholder name: ______________________________________ Card No.:_______-_______-_______-______ Exp. date: ______ / ______ ______ $19 (if eating) ______ Free (if not eating) ______ Free ______ $11 (if eating) 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 22

Community Education - current class catalogs Project Power - Spring/Summer 2019 | Page 23