Registration Form
Parent/Adult (1)___________________________________________________________________________________________________ e-mail address____________________________________________________________________________________________________ Address__________________________________________ Phone (h)______________________ (w)____________________________ City______________________________________________________State___________________ Zip ____________________________ Parent/Adult (2)__________________________________________________________________________________________________ e-mail address____________________________________________________________________________________________________ Address__________________________________________ Phone (h)______________________ (w)____________________________ City_____________________________________________________________Zip______________________________________________ Please include the following information on all preschool registrations:
Optional demographic information for all other registrations: we collect this information to ensure equitable programs that serve everyone in our community
Child’s gender: Female Male Child’s racial/ethnic background (mark all boxes that apply):
Gender: Female Male Other ________________________
White Native Hawaiian or Other Pacific Islander
Racial/ethnic background (mark all boxes that apply): White Native Hawaiian or Other Pacific Islander
Black/African/African American Hispanic or Latino
Black/African/African American Hispanic or Latino
American Indian/Alaskan Native Asian
American Indian/Alaskan Native Asian Other __________
Child’s date of birth:_______________________________________
Date of birth:______________________________________________
Participant Name______________________________________
Participant Name______________________________________
If child: DOB__________ M F School____________________
If child: DOB__________ M F School____________________
Class Title_____________________________________________
Class Title_____________________________________________
Class #_____________________ Fee_______________________
Class #_____________________ Fee_______________________
Total Fees________________________________________
Check #_________________________________________
Please enclose a check, payable to ISD #283, or register online with Mastercard, Visa or Discover. Questions? Call one of the Community Education offices listed below. Emergency Contact ______________________________________________Phone___________________________________________ Special Needs?__________ Sr Program Member Yes No
Ucare #______________________________________________
Permission and Waiver I hereby agree to allow my child, and/or myself to participate in the above named St. Louis Park activity. In consideration of you accepting this registration, I hereby, for myself and my heirs, waive any and all rights and claims for damages I may have against ISD #283 or the City of St. Louis Park and its representatives, for any and all injuries from whatever cause suffered by the above participation in the indicated activity. In case of emergency, the staff has my permission to use their judgement with regard to treatment until I can be contacted. I also understand that the information that I have provided will be distributed to individuals involved with each program.
Parent/Guardian Signature__________________________________________________________________DATE__________________________ Please send your registration to one of these offices. You can register for both adult and youth classes on the same form.
AQ/GYMNASTICS/BIRTH-5 Central Community Center 6300 Walker St. St. Louis Park, MN 55416 Phone: 952/928.6777
62
YOUTH ENRICHMENT
SENIORS & ADULTS
St. Louis Park Middle School 2025 Texas Ave. S. St. Louis Park, MN 55426 Phone: 952/928.6399
Lenox Community Center 6715 Minnetonka Blvd. St. Louis Park, MN 55426 Phone: 952/928.6442
www.slpcommunityed.com