Roseville Community Education - Welcome

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Try Online Registration - it’s fast & easy!
www.ISD623.Org/commed
Click on Community Education Online Registration
You may use this form to register for any class(es) listed in the brochure.
Participant Full Name _____________________________________________________________________________
Street Address __________________________________________ City _______________________ Zip __________
Home Phone ________________ Work Phone ________________ Mobile ___________________________________
Emergency Phone ______________________________________ Other ___________________________________
Email Address ___________________________________________________________________________________
q Male q Female Birthdate ___________________ Age ______________________
Special health concerns (accommodations, disability, allergy, or special need we should be aware of):
_______________________________________________________________________________________________
Class # _____________________ Title _________________________________________________ $ ____________
Class # ____________________ Title __________________________________________________ $ ____________
Class # _____________________ Title __________________________________________________ $ ____________
AQUATICS
1 st Class Choice _________________________ Day_____ Time____________________________ $ ____________
2 st Class Choice _________________________ Day_____ Time____________________________ $ ____________
Youth Ages 0-18
Parent/Guardian Full Name _________________________________________________________________________
Persons authorized to pick up child/ren other than parent _________________________________________________
Student’s Grade _______ School Attending ___________________________ Classroom Teacher __________________
After class my child:
q Is registered to attend Friendship Connection
q Will walk home q Will be picked up by_________________________________________________
Discounts
Participant’s UCare ID# (If applicable) _______________________ UCare Member Discount Total $ _____________
Senior 60+ q Yes q No
Payment Information
Total Registration Amount $ _______________________________
q Cash q Check (Make Checks Payable to Roseville Area Schools)
q Mastercard q Visa q Discover q American Express (please fill out info below)
Authorized Signature ___________________________________________________ Date____________________
Cardholder’s First Name __________________________________ Card Holder’s Last Name__________________
Credit Card number_____________________________________________________________________________
Expiration Date _________________________________________
Visit us online at www.ISD623.Org/CommEd
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