( 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 . Emergency contact name Phone No .

Class / Event Participant

Medical conditions or needs : Please specify information to instructor they may need to be aware of ( dietary , behavioral or other ). Primary staff / caregiver must stay , if there is an active seizure disorder .

Seizure Disorder ( active )

Behavioral ASL Interpreter Wheelchair Walker Autistic Allergies __________________________ Other ____________________________________________ Staff must remain on site : Yes No Photo Release : Yes No

Payment information :

Participant total : $ ________ Staff total : $ ________ UCare member No .: ____________________________ Paper check : Payable to “ Anoka-Hennepin School District ”

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 classes . Contact us for further information 763-506-1290 . or FAX form to 763-506-1299 or CALL us at 763-506-1290

Check out our new and simple online registration and payment options .

ahschools . ce . eleyo . com