Community Education - current class catalogs Youth activities and classes - Summer 2015 | Page 15

REGISTRATION

Student Name ____________________________________________ Gender

M

F Birth Date _______________ Grade ______

Participants must be age indicated by class strart date.

Address __________________________________________________________________________ School __________________________
City _________________________________________ Zip _______________ Phone No. (Home) ________________________________
Accommodation Needs _____________________________________________________________________________________________
Parent/Guardian Name _________________________________________ (Work) _____________________ (Cell) __________________
Parent/Guardian Email Address ______________________________________________________________________________________
Providing us with an email address allows us to contact you in case of schedule changes.

Cash, Check No. ___________ or

Visa

MasterCard

Discover (Check one) Amount $__________________________________

Cardholder Signature required _____________________________ Exp. Date _________/_________

Checks payable to Anoka-Hennepin Dist. No. 11

Credit Card No. ________ ________ ________ ________ — ________ ________ ________ ________ — ________ ________ ________ ________ — _______ ________ ________ ________
Course Name _________________________________ Location ___________________ Number _________________ Fee __________
Course Name _________________________________ Location ___________________ Number _________________ Fee __________
Course Name _________________________________ Location ___________________ Number _________________ Fee __________
Course Name _________________________________ Location ___________________ Number _________________ Fee __________
Please check one:

My child will be pcked up each day

My child has permission to walk home

Registr