( 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 .

Special Accomodations : � Wheelchair � Allergies ______________________________ � Other _____________________________ Staff must remain on site : � Yes � No Photo Release : � Yes � No � ASL Interpreter ___________________

Animal Humane Society Tour

Bingo Jan 8 Feb 6 Mar 19 Apr 9 Apr 23 Butterfly Paper Roll Cat in the Moon Painting Crafty Artists Art Night ! Feb 11 Apr 10 Crazy Puff Pizza Dinner at Acapulco Dinner at Davanni ’ s Dinner at Sammy ’ s Pizza and Restaurant Easy Chicken Parmesan Friday Fun Night ! Friday Night Bowling Jan 10 Jan 31 Feb 21 Mar 7 Mar 21 Apr 25 Gluten-Free Pizza Gluten-Free Vanilla Cupcakes Grass Heads Hawaiian Dance Party ! Inclusion Card Making Inclusion Cooking class- Cream Cheese Mints

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 .

$ 12 ___

$ 11 ___ $ 11 ___ $ 11 ___ $ 11 ___ $ 11 ___ $ 12 ___ $ 22 ___

$ 9 ___ $ 9 ___ $ 19 ___ $ 22 ___ $ 22 ___ $ 25 ___ $ 19 ___ $ 12 ___

$ 22 ___ $ 22 ___ $ 22 ___ $ 22 ___ $ 22 ___ $ 22 ___ $ 22 ___ $ 19 ___ $ 12 ___ $ 15 ___ $ 12 ___ $ 14 ___

Payment information :

Participant total : $ __________ Staff total : $ __________ UCare member No .: _________________________________ Paper check : Payable to “ Anoka-Hennepin Schools ” All checks processed electonically . Credit card : Cardholder name ____________________________________________________ Card No .:__________ - __________ - __________ - _________ Exp . date : _______ / _______

Inclusion Pickleball Inclusion Snacks and Games Indoor T-Ball Intro to Pickleball Karate Jan 27 - Mar 3 Mar 24 - Apr 21 Lego Social Lidya the Ladybug Painting Make a Trinket Box Merry Music Makers Mini Gumball Machine Monday Bowling League Jan 13 - Feb 10 Feb 24 - Mar 17 Mar 24 - Apr 14 Apr 21 - May 12 Movie and Subs Movie and Tacos Music with Claire – Disney songs Music Workshop Paint a Gourd Paper Lantern Paramount Theater – Mary Poppins Pool Party ! Project Power Bowling Invitational Sand Art Sloppy Joes String Eggs Suncatcher Window Painting The Fun Lab

$ 12 ___ $ 6 ___ $ 35 ___ $ 12 ___

$ 30 ___ $ 30 ___ $ 12 ___ $ 22 ___ $ 14 ___ $ 32 ___ $ 18 ___

$ 65 ___ $ 65 ___ $ 65 ___ $ 65 ___ $ 19 ___ $ 19 ___ $ 12 ___ $ 8 ___ $ 12 ___ $ 12 ___ $ 12 ___ $ 12 ___ $ 22 ___ $ 12 ___ $ 19 ___ $ 12 ___ $ 12 ___ $ 39 ___

The King Painting Thursday Night Pickleball Valentine ’ s Day Cookie Water Aerobics Jan 17 Mar 28 Apr 11 Zumba Moving & Grooving

Staff / Caregiver Registration Animal Humane Society Tour

$ 8 ___

$ 22 ___ $ 32 ___ $ 19 ___

$ 15 ___ $ 15 ___ $ 15 ___ $ 15 ___

Crazy Puff Pizza $ 19 ( if eating ) ___ Dinner at Acapulco $ 22 ( if eating ) ___ Dinner at Davanni ’ s $ 22 ( if eating ) ___ Dinner at Sammy ’ s Pizza and Restaurant $ 25 ( if eating ) ___ Easy Chicken Parmesan $ 19 ( if eating ) ___ Gluten-Free Pizza $ 22 ( if eating ) ___ Gluten-Free Vanilla Cupcakes $ 19 ( if eating ) ___ Hawaiian Dance Party ! $ 15 ( if eating ) ___ Movie and Subs $ 19 ( if eating ) ___

Sloppy Joes $ 19 ( if eating ) ___ The Fun Lab

$ 39 ( if participating )___ Valentine ’ s Day Cookie $ 19 ( if eating ) ___

Check out our simple online registration and payment options . ahschools . ce . eleyo . com

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 CALL us at 763-506-1290

Feel the power of you ! discovercommunityed . com