Community Education - current class catalogs Project Power - Summer 2019 | Page 15

Summer 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
Backstage at Northern Starz
______ $10
Board Games and Root Beer Floats
______ $12
Bowling League
June 3
(bowling & pizza)
______ $55

(bowling only)
______ $30

(eating only)
July 8
(bowling & pizza)
______ $55

(bowling only)
______ $30

(eating only)
Aug. 5
(bowling & pizza)
______ $55

(bowling only)
______ $30

(eating only)
Canvas Painting
______ $29
Concert in the Commons
-Music Junkies

______ $9
Dinner at Dairy Queen
Jun. 20
______ $15
Aug. 13
______ $15
Dinner at Golden Corral
July 1
______ $22
Aug. 2
______ $22
Dinner at Pizza Ranch
______ $22
Driftwood Wall Art
______ $15
Feed My Starving Children
______ $5
Fire Station Tour
______ $9
Friday Night Bowling
June 14
(bowling & pizza)
______ $25

(bowling only)
______ $15

(eating only)
July 19
(bowling & pizza)
______ $25

(bowling only)
______ $15

(eating only)
Aug. 9
(bowling & pizza)
______ $25

(bowling only)
______ $15

(eating only)
Grand Slam
______ $19
Guys and Dolls Musical
______ $39
Kickball
______ $35
Laughter Yoga in the Park
______ $15
Lilli Putt
______ $19
Mosaic Art
______ $10
Movie and Pizza at the Theater
______ $19
Party in the Park
______ $25
Rainforest Cafe and Moose Mountain `
______ $45
Skyrock Farms
______ $49
Special Olympics Summer Games
______ $10
Swimming in the Sun
______ $15
The True Story of the
Three Little Pigs Musical
______ $25
Twins Game
______ $35
Emergency contact name
Staff
______ $55
______ $30
______ $25
______ $55
______ $30
______ $25
______ $55
______ $30
______ $25
______ $9 (if eating)
______ $9 (if eating)
______ $19 (if eating)
______ $19 (if eating)
______ $15 (if eating)
______ Free
______ Free
______ $25
______ $15
______ $10
______ $25
______ $15
______ $10
______ $25
______ $15
______ $10
______ $15 (if participating)
______ $29
______ $10 (if participating)
______ $15
______ $15 (if eating)
______ $35
______ $39
______ Free
______ Free
______ $19
______ $29
DID YOU KNOW? Many UCare members can receive up to a $15 discount on most
Community Education classes. Contact us for further information 763-506-1290.
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:
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 registration to 763-506-1299
Or CALL registration to 763-506-1290
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