ࡱ> uwt'` bjbjDD X&&4X 7777487R0808080808 9 9 9RRRRRRR$~ThVCR; 9 9;;CR0808XR;;;;0808R;;R;;K|M08$8 !*75;LM|nR0R/LWK;FW$MWM 9LW96;9,9f 9 9 9CRCR; 9 9 9R;;;;$@$@$(,T Community Services Division Registration Form Parent/Guardian Name Primary Email Address Home Phone Day Phone Other Phone Address City State Zip Signature (Adult participant or Parent/Guardian if under 18) 91ԭ Community Services Division does NOT provide accident insurance for participants in any of its programs or activities. Participants assume all inherent risk of injury resulting from their involvement in programs or activities. The 91ԭ Community Services Division often takes photographs of classes or programs to use in brochures and on the web, including social media. If you do not want pictures of you or your child used, please call our office at 507.664.3649. I am paying by cash check # (payable to Community Services) MasterCard Visa Discover Credit Card # - - - Expiration Date / (MM/YY) Name as it appears on card Cardholder Signature If you qualify for free or reduced meals provided by 91ԭ, and are 0 18 years of age, you are eligible for a scholarship toward your Community Services classes. All participants will pay a percentage of the fee. Call 507.664.3649 or stop in our office to register. **We want everyone to be able to participate in our programs help make it possible by donating to the 91ԭ Community Services Scholarship Fund. Id like to contribute $________ to the scholarship fund.** Complete for Youth and Adult Registrations Registration begins immediatelyClass #Class TitleName of ParticipantBirth DateGrade in SchoolFee Complete for Early Childhood Family Education Registration Registration begins immediatelyClass #Class TitleChild/ren AttendingParent/s AttendingBirth DateFee Please mail or return this form to: 91ԭ Community Services Division 1651 Jefferson Parkway, Northfield, MN 55057 -./CDLMY[efiop{}ǵuhZhhBWhJ >*OJQJaJhBWhJ OJQJaJhBWhrCJOJQJaJh15CJOJQJ\aJhJ 5CJOJQJ\aJ%hBWhr5>*CJOJQJ\aJ"hBWhr5CJOJQJ\aJhBWhr5CJOJQJ\hBWhr5CJOJQJaJ0hBWhr5CJOJQJaJfHq ./[} xppg$ 'a$$a$gdJ $ 'a$gdJ $ 'a$gdJ $d^a$$  !'dha$$  'dha$ $ 'dha$ $ 'a$,$d%d&d'd-DM NOPQ  ? w ! ) - 6 ? 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