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Program Registra�on Form |
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PARENT / GUARDIAN / ADULT PARTICIPANT NAME: |
HOME PHONE:( |
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STREET ADDRESS: |
WORK PHONE:( |
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CITY: |
CELL PHONE:( |
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STATE: |
ZIP: |
E-MAIL ADDRESS: |
Check this box if you wish to opt out |
By giving us your e-mail we can no�fy you of program changes, cancella�ons, and new programs that will interest |
of program updates via email |
you and your family. Your e-mail address will not be shared with any other organiza�on. You will not be spammed. |
HOME LANGUAGE: |
EMERGENCY CONTACT NAME / RELATION( If different from above): |
EMERGENCY CONTACT PHONE:( |
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DATE OF BIRTH
M / F
PARTICIPANT’ S First & Last Name
CLASS #
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Subtotal UCare Discount
( Adult Programs Only)
UCare ID #
Total Cost:
* Special Needs: For op�onal a�er-school programs we do not have access to medical records or supplies kept in the nurses office and our ability to provide support is limited. If you have any special needs or health concerns that would impact your child’ s par�cipa�on in this ac�vity, please email thagen @ isd622. org or call 651-748-7634 no later than one week before the class begins. * Photos: Par�cipant / student pictures will be included in school district publica�ons and online. However, any par�cipant / student or parent may request that photos not be published. If you do not want your / your child’ s photographs used, please contact our office.
I have read, understand, and agree to the Community Educa�on Policies as found on page 50 Parent / Guardian Signature( if minor) or Adult Par�cipant’ s Signature
How did you hear about us? Catalog Flyer Website Email Newspaper Word of Mouth Other
PAYMENT INFORMATION: MasterCard Visa Discover Check: # ________( Payable to“ District 622”)
Card Number: __ __ __ __- __ __ __ __- __ __ __ __- __ __ __ __ Exp. Date: ___ / ___ Signature: ________________________________ Date:____________