Safety Village Registration 2024

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Safety Village will be held June 17-June 28, 2024

Please indicate which session: *

8:00- 10:00 AM

10:30- 12:30 AM

Child's Name (First & Last) *

Gender *

Child has attended camp before: *

Child's Date of Birth *

YYYY

My Child is: *

5 years old and completed kindergarten

6 years old

7 years old

Address, City, Zip *

Name of Parent/ Guardian (First & Last) *

Phone Number- Children will practice a number to call in case of an emergency. Please indicate which phone number you would like them to know. (include area code) *

Email *

Does your child have a special need? If yes, please explain. *

Is your child's primary language English? If no, please identify primary language. *

If signing up siblings/friends, do you want them in the same group? We will do our best to comply. *

Yes

Name(s) of sibling(s)/friend(s) *

My Child, has my permission to participate in the Safety Village Program. I waive and release all members of the Board and anyone involved in the program from any claim or liability in the event of injury. In the event my child may require medical and/or surgical care if I am unable to be reached, I hereby give my consent to medical and/or surgical treatment to (list hospital below) and to Dr. (list doctor below) or his/her designee to provide this care. I agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent.
*

My child has permission to be photographed/video recorded for use by Safety Village and its promotion. *

Comments/Details Camp Staff need to know... *

Please choose T-shirt size (these are youth sizes and they tend to run small) *

Small (8-10)

Medium (10-12)

Large (14-16)

X-Large

By clicking on I agree, I consent to all information above and give my child permission to attend Safety Village. *

I Agree, to all terms and agreements

Name on card for payment (information used to confirm payment) *

Last 4 numbers of card (information used to confirm payment) *

Please use the below link for credit card payment or mail a check. USE PAYMENT LINK BEFORE SUBMITTING REGISTRATION! *

https://swipesimple.com/links/lnk_5b00f802

Mailing a check for $100 to Safety Village at PO Box 5551 Coralville, IA 52241

Required

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