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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 However , any par�cipant / student or parent may request that photos not be published .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 :____________