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PARTICIPANT’S
First & Last Name
M/F
DATE
OF BIRTH
CLASS NAME
COST
)
Total Cost:
UCare ID #
(Adult Programs Only)
UCare Discount
Subtotal
TOTALS
EMERGENCY CONTACT PHONE: (
MasterCard
Visa
Discover
Check: # ________ (Payable to “District 622”)
Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Exp. Date: ___ / ___ Signature: ________________________________ Date:____________
PAYMENT INFORMATION:
Parent/Guardian Signature (if minor) or Adult Participant’s Signature
I have read, understand, and agree to the Community Education Policies as found on page 50
*Special Needs: For optional after-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 participation in this activity, please email [email protected] or call 651-748-7446 no later than one week before the class begins.
*Photos: Participant/student pictures will be included in school district publications and online. However, any participant/student or parent may request that photos not be published.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.
CLASS
#
)________________________________
)_________________________________
)_________________________________
Check this box if you wish to opt out of program updates via email
EMERGENCY CONTACT NAME / RELATION (If different from above): ____________________________________
By giving us your e-mail we can notify you of program changes, cancellations, and new programs that will interest
you and your family. Your e-mail address will not be shared with any other organization. You will not be spammed.
E-MAIL ADDRESS:
ZIP:
CELL PHONE:
CITY:
STATE:
WORK PHONE: (
STREET ADDRESS:
(
HOME PHONE: (
PARENT/GUARDIAN/ADULT PARTICIPANT NAME:
Office: 651-748-7630 • Fax: 651-748-7497 • www.isd622.org/ce
Adult Registrations to Gladstone Center • 1945 Manton Street, Maplewood, MN
All other registrations to District 622 Community Education • 2520 12th Avenue East, North St. Paul, MN 55109
Program Registration Form