District 622 Community Education Youth Programs Youth Programs Summer 2017 - Page 2

Registration
Please register your child based on the grade level ( s ) he will be entering in the fall of 2017 .
Online www . isd622 . org / ce Click “ Register Online ”
Phone 651-748-7435 Have credit card & class info ready
Fax 651-748-7497 Send complete registration form
Mail Community Education – Youth 2520 E 12th Ave North St . Paul , MN 55109
Registration Form for Youth Enrichment and Swim Lessons ( Adventure Connection and Summer EPIC are online registration – call for assistance )
PARENT / GUARDIAN NAME : HOME PHONE : ( )__________________ ____ CELL : ( ) STREET ADDRESS : CITY : STATE : ZIP :
EMAIL ADDRESS :
By giving us your email we can notify you of program changes , cancellations , and new programs that will interest you and your family . Your email address will not be shared with any other organization . You will not be spammed .
EMERGENCY CONTACT NAME / RELATION ( different from above ): EMERGENCY CONTACT PHONE : ( ) WHERE WILL YOUR CHILD BE GOING AFTER CLASS ? ( Youth Enrichment Only )
Check this box to opt out of program updates via email
PICKED UP BY ADVENTURE CONNECTION WALKING HOME
CLASS # PARTICIPANT ( FIRST , LAST ) M / F
DATE OF BIRTH
CLASS NAME
COST
Special Needs Note : For optional summer programs we do not have access to medical records or supplies kept in the nurse ’ s office and our ability to provide support is limited . If you have any special needs or health concerns that would impact your child ’ s participation in this activity , please email apolos @ isd622 . org or call 651-748-7432 no later than one week before the class begins .
TOTAL COST
I HAVE READ , UNDERSTAND , AND AGREE TO THE COMMUNITY EDUCATION POLICIES AS FOUND ON WWW . ISD622 . ORG / CE
PARENT / GUARDIAN SIGNATURE : PAYMENT INFORMATION :
MASTERCARD VISA DISCOVER CHECK : # __________ ( Payable to “ District 622 ”) CARD NUMBER : ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ EXP . DATE : ___ / ___
SIGNATURE : DATE : 2