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