Summer 2021 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 Phone No . Emergency contact name Phone No .
Class / Event Participant Staff
Bead Bugs |
___ $ 15 |
___ Free |
Bingo June 8 |
___ $ 9 |
___ Free |
July 6 |
___ $ 9 |
___ Free |
August 18 |
___ $ 9 |
|
Bob and the Beachcombers |
___ $ 9 |
|
Bowling June 25 |
___ $ 19 |
___ $ 12 ( if bowling ) |
July 23 |
___ $ 19 |
___ $ 12 ( if bowling ) |
August 27 |
___ $ 19 |
___ $ 12 ( if bowling ) |
Bowling League June 7-28 |
___ $ 55 |
___ $ 39 ( if bowling ) |
July 5-26 |
___ $ 55 |
___ $ 39 ( if bowling ) |
August 2-23 |
___ $ 55 |
___ $ 39 ( if bowling ) |
Cinema Grill |
___ $ 22 |
___ $ 15 |
Dessert and Games |
___ $ 15 |
___ $ 5 ( if eating ) |
Dinner and Treats at DQ July 21 |
___ $ 15 |
___ $ 9 ( if eating ) |
August 24 |
___ $ 15 |
___ $ 9 ( if eating ) |
Fairy of Gnome Home |
___ $ 19 |
___ Free |
Foot Golf |
___ $ 45 |
___ $ 20 ( if playing ) |
Hansel and Gretel Musical |
___ $ 15 |
___ $ 7 |
Kickball |
___ $ 35 |
|
Lilli Putt |
___ $ 22 |
___ $ 15 |
Magic and Comedy in the Park |
___ $ 9 |
|
Pair of 7 Concert |
___ $ 9 |
|
Red , White and Blue Art |
___ $ 15 |
___ Free |
Take Me Out to the Ballgame ! |
___ $ 12 |
|
The Wizard of Oz |
___ $ 15 |
___ $ 7 |
Walk , Roll and Watermelon |
___ $ 10 |
|
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 .
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 No Photo Release : Yes No
Payment information :
Participant total : $ ________ Staff total : $ ________ UCare member No .: ____________________________ Paper check : Payable to “ Anoka-Hennepin School District ”
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 new and simple online registration and payment options at www . ahschools . ce . eleyo . com