Community Education - current class catalogs Project Power - Winter 2020 | Page 15

Winter 2020 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 Class/Event Bingo Jan. 15 Phone No. Emergency contact name Participant Staff ______ $9 Feb. 4 Birdhouse Canvas Art Blue Ox Hockey Game Chocolate Covered Treats ­­­­­­­ Cooking 101-Rice Bowls Cooking at Hy-Vee Creative Clay Tiles Dinner at Acapulco Dinner at Golden Corral Flora and Ulysses Friday Night Bowling Jan. 3 (bowling & pizza) (eating only) (bowling only) ______ $9 ______ $15 ______ $15 ______ $15 ______ $19 ______ $19 ______ $25 ______ $22 ______ $22 ______ $29 ______ $25 ______ $10 ______ $15 ______ $25 ______ $10 ______ $15 Feb. 14 (bowling & pizza) (eating only) (bowling only) Get in the Act Karate Merry Music Makers Minnesota Timberwolves Party at Dave & Buster’s Pizza and Movie at Oak View Pizza and Movie at the Theater Rhythm and Bells Roller Derby Snowman Door Stop Super Bowl Party T-Ball Valentine’s Day Party ______ $25 ______ $10 ______ $15 ______ $10 ______ $35 ______ $45 ______ $59 ______ $35 ______ $25 ______ $10 ______ $15 ______ $19 ______ $9 (if eating) ______ $19 ______ $29 ______ $29 ______ $15 ______ $22 ______ $35 ______ $15 ______ $15 ______ $9 ______ $15 (if eating) ______ $15 (if eating) ______ $19 (if eating) ______ $25 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. _____________________________________ Behavioral Walker Wheelchair Visual impairment Staff must remain on site: Yes No Other: (specify) _____________________________________ _____________________________________ _____________________________________ Payment information: Participant total: ______ $49 ______ $29 (if participating) ______ $19 ______ $15 (if eating) $ ______________ Staff/caregiver total: $ ______________ UCare Member No.: ____________________ Check Number: _______________ Make check payable to: Anoka-Hennepin School District OR Credit card: Cardholder name: ______________________________________ Card No.:_______-_______-_______-______ Exp. date: ______ / ______ Mail completed form and payment: Anoka-Hennepin Community Ed. Attn: Project Power 2727 N. Ferry St., Anoka, MN 55303 Did you know? Many UCare members can receive up to a $15 discount on most Community Education Education classes. Anoka-Hennepin Community Contact us for further information 763-506-1290. Phone No. 763-506-1290 14 Or FAX registration to 763-506-1299 [email protected] Or CALL registration to 763-506-1290