Community Education - current class catalogs Project Power - Winter 2017-18 | Page 15

Winter 2018 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.
Class/Event
Bingo
Participant
___________________________
Staff/caregiver
______ $9
Bowling with Dirk and Perry
Jan. 12
Bowling & pizza ______ $25 ______ $25
Bowling only ______ $15 ______ $15
Pizza only
Feb.16
__________________
Emergency contact name
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)
______ $10 __________________________
Bowling & pizza ______ $25 ______ $25 ASL interpreter:
Yes
No
Bowling only ______ $15 ______ $15 Photo release:
Yes
No (See p. 16)
______ $10 Seizure:
Non-active
______ $19 ______ $12 An active seizure disorder MUST have a primary staff
or caregiver with participant at all times.
Pannekoeken ______ $19 ______ $9 (if eating) Patty Melt and Homemade Fries ______ $19 ______ $9 (if eating)
Pizza only
Brodini Magic Show
Cooking 101
Active
Autistic Behavioral
Wheelchair Visual impairment
Staff must remain on site:
Yes
Walker
No
Other: (specify)
Decorative Votive Candle Holder ______ $15 Dinner at Golden Corral ______ $19 Fitness Walking ______ $19 Games and Dinner at Dave and Buster’s ______ $35 Gentle Yoga ______ $29 Glow in One Mini Golf and Dinner ______ $25 Hot Chocolate Cupcakes ______ $15 Indoor T-Ball ______ $35 Karate ______ $35 Karate Stencil and Movie ______ $15 Merry Music Makers ______ $45 Movie and Lunch at the Theater ______ $19 ______ $15
National Pizza Day and Movie ______ $19 ______ $9 (if eating)
Pool Party at Roosevelt Pool ______ $15 ______ Free
Rhythm and Bells ______ $29 Super Bowl Party ______ $22 ______ $15 (if eating)
The Wiz at Children’s Theater ______ $45 ______ $39
Yarn Wall Hanging ______ $15 Wood Sign Painting at Ladybug Pottery ______ $25
______ $15 (if eating)
______ $29 (if participating)
Payment information:
Participant total:
______ $19 (if participating) Staff/caregiver total:
$ ________________
$ ________________
Check Number:
__________________
Make check p