Lakeville Area Community Education Registration Form      

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Adult Contact Information Self or Parent/Guardian: Name:_________________________________________________________________________________ Attending: Yes No Address: ___________________________________________________________________ City: ________________________ Zip: ________ Phone: Day (_____) ______-_________ Evening (_____) ______-_________ Emergency (_____) ______-_________ Email: ____________________________________@__________.______ Would you like to receive general information on community ed classes and events via email? yes ❑ no ❑ Youth & Adult Enrichment, Aquatics and Small Wonders Preschool Participant Name >J

Youth only Grade & Date of Birth

Class #

Class Title

Start Date & Time

Location

Swim Level

Fee

Total If an after school class, check here if your child is scheduled for Kid Zone (KZ) ❑ (They must check in at KZ before and after the class) Early Childhood Family Education (ECFE) Classes & Happenings Register for classes in priority of order. The ECFE sliding fee scale is listed on page 39. A second child registering for the same class receives a 50% discount. Please indicate discount on this form. "   ]>J

Date of Birth

Sibling Care Name & Date of Birth

Class/ Happenings Class #

Class Title and Level

If your second class choice is available, check here if you would like both classes ❑

Fee

Total

FOR ALL REGISTRATIONS Please list any medical concerns, special needs or allergies that Community Education should be aware of. Participant Name and Concern: Participant Name and Concern: Media Release: I authorize ISD #194 employees to take and use photographs/video of me and/or my child for use in class activities, District publications, District promotions and on the District Web sites. Participant/Parent/Guardian Signature: ___________________________________________________ Date: _________________ Payment Information I am paying $ ____________ by Cash ____ Check ____ Charge my Visa ____ Mastercard ____ Discover ____ Name as written on Card: First

M.I.

Last

Signature: Card #:

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Check #

Cash $

Date Received

CC Date

By

Ver

DB

CL

Conf

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