Summer 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

Anoka Aquatic Center		______ $ 14
Art Night		______ $ 19
Bingo :
June 28		______ $ 11
July 20		______ $ 11
August 17		______ $ 11
Bowling Pin Art		______ $ 19
Dessert in the Park		______ $ 12		______ $ 4 ( if eating )
Dinner and Treats at DQ : June 21		______ $ 15		______ $ 12 ( if eating )
Cheesburger	Hot dog		Chicken strip basket
August 23		______ $ 15		______ $ 12 ( if eating )
Cheesburger	Hot dog		Chicken strip basket
Dinner at Acapulco		______ $ 22		______ $ 22 ( if eating )
Dinner at Sammy ’ s Pizza		______ $ 25		______ $ 25 ( if eating )
Donuts with Dad		______ $ 12		______ $ 4 ( if participating )
Feed My Starving Children		______ $ 9		______ Free
Fire Station Tour		______ $ 9
Fruit Pizza		______ $ 19
Friday Night Bowling : June 9		______ $ 22		______ $ 22 ( if bowling )
July 14		______ $ 22		______ $ 22 ( if bowling )
August 11		______ $ 22		______ $ 22 ( if bowling )
Hawaiian Bowling Night		______ $ 22		______ $ 22 ( if bowling )
Introduction to Bocce Ball		______ $ 9
Kickball		______ $ 35
Lilli Putt		______ $ 22		______ $ 19 ( if golfing )
Monday Night Bowling : June 5-26		______ $ 59
July 10-31		______ $ 59
Movie at Dusk		______ $ 9
Painted Rocks Tic-Tac-Toe Board		______ $ 22
Pineapple Jar		______ $ 22
Performance in the Park : The Backyard Band		______ $ 9
Tricia and the Toonies		______ $ 9
Project Power Bowling Invitational		______ $ 22
Rice Art		______ $ 19
Star Wars Bowling Night		______ $ 22		______ $ 22 ( if bowling )
Thumbelina		______ $ 24		______ $ 24
Walking Tacos		______ $ 19

• 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 .: _____________________________

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 - Summer 2023 | Page 7

Summer 2023 registration form