Winter 2022-23 registration form

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

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

Name of Participant name : ________________________________ Phone : _______________ Group Home : ________________

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

Art Night	____ $ 15
Bingo
December 7	____ $ 11
January 25	____ $ 11
February 22	____ $ 11
Bowling League	____ $ 59
Bowling Night	____ $ 21
Card Making	____ $ 15
Country Line Dancing	____ $ 19
Cupcakes !	____ $ 19
Dinner at Acapulco	____ $ 22	____ $ 22 ( if eating )

Dinner at Sammy ’ s Pizza	____ $ 25	____ $ 25 ( if eating )
Disney Holiday Sing Along	____ $ 15
Friday Night Bowling December 9	____ $ 21	____ $ 21 ( if bowling )

January 13 ____ $ 21 ____ $ 21 ( if bowling )

February 3	____ $ 21	____ $ 21 ( if bowling )
Graham Cracker Gingerbread House	____ $ 19
Holiday Light Tour	____ $ 19	____ $ 19
Holiday Sugar Cookies	____ $ 19
Indoor T-Ball	____ $ 35
Karaoke Party	____ $ 15
Karate	____ $ 39
Merry Music Makers	____ $ 55
Mosaic Art	____ $ 30
Muffin Tin Dinner	____ $ 25
Neon Glow Dance Party	____ $ 35
No-Sew Fleece Tie Blanket	____ $ 35	Pick one :	5:30	6:00	6:30

Pizza & Movie at Oak View	____ $ 15	____ $ 15 ( if eating )
Scrooge	____ $ 23	____ $ 23
Snowman Pot	____ $ 19
Sparkly Winter Painting on Canvas	____ $ 19

Sponge Painting Heart Tote Bag	____ $ 19
Talent Show	____ $ 35

The Fun Lab ____ $ 35 ____ $ 35 ( if participating )

• Payment is due at the time of registration .

• Refund and cancellation policy : requests with at least five business days notice from the class start date are eligible for a refund minus a $ 10 processing fee . Refund requests with less than five business days notice from the start of class are not eligible for a refund . Combines individuals with intellectual disabilities and those without intellectual disabilities to participate in classes and activities together !

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 Photo Release : � Yes

Payment information :

� No

Participant total : $ _________ Staff total : $ _________ UCare member No .: _____________________________

Use your credit or donate to Community Ed .: $ _______ Paper check : Payable to “ Anoka-Hennepin School District ” All checks processed electonically . 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

or FAX form to 763-506-1299 or CALL us at 763-506-1290

Check out our simple online registration and payment options .

ahschools . ce . eleyo . com

Community Education - current class catalogs Project Power - Winter 2022 | Page 7

Winter 2022-23 registration form