Community Education - current class catalogs Project Power - Winter 2015 | Page 19
Winter 2014-2015 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: ________ / _____ / _________
Month
Legal Guardian/Emergency Contact:
Day
Year
REQUIRED
Guardian Name: ________________________________________________ Phone: ____________________________
SPORTS &
EXERCISE
OUT & ABOUT
MUSIC
& THEATRE
LAUGH
& LEARN
COOKING ARTS &
& DINING CRAFTS
Emergency Contact: ____________________________________________ Phone: ____________________________
(Emergency Contact must be able to be reached during class time, not a voice mail or machine.)
Calendar Crafting
Fabric Tie Wreath
Handmade Birdfeeders
Valentine Mason Jar Vase
Bars in a Jar
Cooking 101-Chili & Cornbread
Cooking 101-Taco Tuesday
Dinner at Old Country Buffet
Holiday Cookie Bake
BINGO
Calls from the Wild-Virtual
Field Trip
Holiday Party
Life Skills-Healthy Relationships
Movie & Dinner
Wii Party
Charlie & the Chocolate Factory
Dance Studio
Holiday Caroling
Merry Music Makers
Project Power LIVE!
Rhythm & Bells
Animal Humane Society
Shelter Tour
Jan 23
Jan 30
Grand Slam
Tropics Water Park
Wood Crafting
Bowling & Pizza with Dirk
& Perry
Fitness Walking
Floor Hockey
Kickball
Payment Information:
Participant ______ $19
Participant ______ $19
Participant ______ $15
Participant ______ $19
Participant ______ $15
Participant ______ $15
Participant ______ $15
Participant ______ $15
Participant ______ $19
Participant ______ $9
Participant ______ $15
Participant ______ $15
Participant ______ $15
Participant ______ $15
Participant ______ $15
Participant ______ $15
Participant ______ $29
Participant ______ $5
Participant ______ $45
Participant ______ $29
Participant ______ $29
Medical conditions
or personal needs:
Staff ______ Free
Staff ______ Free
Staff ______ $15
Primary caregiver must stay,
if there is an active seizure disorder.
Allergies:
Food
Medication
(Specify)
__________________________
ASL Interpreter:
Staff ______ $9
Staff ______ Free
Staff ______ $9
Staff ______ Free
No
Photo Release:
Staff ______ Free
Staff ______ Free
Yes
Yes
No
(See page 16)
Seizure:
Active
Non-Active
Autistic
Behavioral
Walker
Wheelchair
Visual Impairment
Staff Must Remain on Site:
Yes
No
Other: (Specify)
______________________
Participant ______ $9
Participant ______ $9
Participant ______ $19
Participant ______ $15
Participant ______ $9
Staff ______ Free
Staff ______ Free
Staff ______ $15
Staff ______ Free
Participant ______ $19
Staff ______ $19
Staff ______ $9 (pizza only)
Staff ______ Free
Participant ______ $15
Participant ______ $29
Participant ______ $29
Participant Total $ ______________
Check #: _____________ OR Credit Card:
Make check payable to: Anoka-Hennepin School District
Credit Card #:
-
Mail completed form
and payment to:
Project Power
Attn: Julie Johnson
2727 N. Ferry Street
Anoka, MN 55303
Or FAX the form to 763-506-1299
Or CONTACT Julie at 763-506-1290
This form is also available in
digital form online at
www.discovercommunityed.com
Staff Total $ ________________
Cardholder Name:___________________________________
-
17
Exp. Date: _______ / _______