District 622 Community Education Youth Programs Youth Programs Summer 2018 | Page 2

Registration Please register your child based on the grade level (s)he will be entering in the fall of 2018. Online www.isd622.ce.eleyo.com Phone [phone] Have credit card & class info ready Fax Mail or Walk-in 651-748-7497 Community Education–Youth Send complete 2520 E 12th Ave registration form North St. Paul, MN 55109 Registration Form (Adventure Connection and EPIC Summer are online registration–call 651-748-7432 for assistance) PARENT/GUARDIAN NAME: HOME PHONE: ( ) CELL: ( ) STREET ADDRESS: CITY: STATE: 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. ZIP: Check this box to opt out of program updates via email EMERGENCY CONTACT NAME / RELATION (different from above): EMERGENCY CONTACT PHONE: ( ) WHERE WILL YOUR CHILD BE GOING AFTER CLASS? (Youth Enrichment Only) PICKED UP BY CLASS # ADVENTURE CONNECTION PARTICIPANT (FIRST, LAST) M/F DATE OF BIRTH WALKING HOME CLASS NAME 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 there are special needs or health concerns that would impact your child’s participation in this activity, please email [email protected] or call 651-748-7432 no later than one week before the class begins. COST TOTAL COST I HAVE READ, UNDERSTAND, AND AGREE TO THE COMMUNITY EDUCATION POLICIES AS FOUND ON WWW.ISD622.ORG/POLICY PARENT/GUARDIAN SIGNATURE: PAYMENT INFORMATION: MASTERCARD VISA DISCOVER CHECK: # __________ (Payable to “District 622”) CARD NUMBER: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___EXP. DATE: ___ / ___ SIGNATURE: 2 DATE: