Community Education - current class catalogs Project Power - Winter 2019

Winter 2019 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 Participant Emergency contact name Staff Bingo Jan. 15 ______ $9 Feb. 28 ______ $9 Bowling with Dirk and Perry Jan. 18 Feb. 15 (bowling & pizza) ______ $25 ______ $25 (bowling only) ______ $15 ______ $15 (eating only) ______ $10 (bowling & pizza) ______ $25 ______ $25 (bowling only) ______ $15 ______ $15 (eating only) Charlotte’s Web ______ $10 ______ $12 ______ $9 Cooking 101 Better than Takeout Fried Rice and Lo Mein ______ $19 ______ $9 (if eating) Panera Bread’s Copycat Mac and Cheese ______ $19 ______ $9 (if eating) Dinner at Denny’s ______ $19 ______ $9 (if eating) Dinner at Golden Corral Buffet and Grill ______ $19 ______ $15 (if eating) Fitness Walking ______ $19 Fleece Pillows ______ $15 Glow in One Mini Golf and Pizza ______ $25 ______ $19 (if participating) Indoor T-Ball ______ $35 Karate ______ $35 Merry Music Makers ______ $45 Minnesota Blue Ox Hockey Game ______ $15 ______ $9 Movie and Lunch at Cinema Grill ______ $15 ______ $12 Paint with Snow ______ $12 Pizza and Movie ______ $19 Rhythm and Bells ______ $29 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 Visual impairment Staff must remain on site: Yes No Other: (specify) _____________________________________ _____________________________________ _____________________________________ Payment information: Participant total: $ ______________ Staff/caregiver total: $ ______________ Check Number: ______ $15 Phone No. _______________ Make check payable to: Anoka-Hennepin School District OR Credit card: Cardholder name: Roller Derby ______ $25 ______ $19 ______________________________________ Soft Pretzels and Cheese Sauce ______ $15 ______ $9 (if eating) Uno and Root Beer Floats ______ $12 Card No.:_______-_______-_______-______ Wood Sign Painting Stencil Choice: ______ $25 ___ Home Sweet Home ___ Life is Short Lick the Spoon ___ Friends ___ Believe Did you know? Many UCare members can receive up to a $15 discount on most Community Education classes. Contact us for further information 763-506-1290. 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 14

Community Education - current class catalogs Project Power - Winter 2019 | Page 15