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

Participant / Staff information:( No participant substitution without prior notice.)

( ONE FORM PER PERSON / THIS FORM MAY BE REPRODUCED)

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 / caregiver Medical conditions or needs:

Please specify information to instructor they may need to be aware of( dietary, behavioral or other).

Allergies: Food Medication( specify)

__________________________ ASL interpreter: Yes No Photo release: Yes No( See p. 16)

Seizure: Active Non-active

An active seizure disorder MUST have a primary staff or caregiver with participant at all times.

Autistic Behavioral Walker Wheelchair

Payment information:

Participant total: staff / caregiver total: Check Number:

$ ________________ $ ________________

__________________

Make check payable to: Anoka-Hennepin School District

OR Credit card:

Cardholder name:

Visual impairment Staff must remain on site: Yes No

Other:( specif y)

___________________________________________

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 registration to 763-506-1299 Or CALL registration to 763-506-1290