( 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.

Special Accomodations: o Wheelchair o Allergies ______________________________ o Other _____________________________ Staff must remain on site: o Yes o No Photo Release: o Yes o No o ASL Interpreter ___________________

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.

Participant total: $ __________ Staff / Caregiver total: $ __________

Paper check: Payable to“ Anoka-Hennepin Schools”( All checks are processed electonically.)

Credit card: Name:__________________________________________ Card No.:____________- ____________- ____________- ___________ Exp. date: _________ / _________

UCare Healthy Benefits Card No.: ____________- ____________- ____________- ___________ Exp. date: _________ / _________

Mail form and payment to Anoka-Hennepin Community Ed. Attn: Project Power 2727 N. Ferry St., Anoka, MN 55303

or FAX form to 763-506-1299 and call to make payment at 763-506-1290

or easy online registration and payment option. Go to ahschools. ce. eleyo. com

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