Safety Town Student Reservation 2024

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What is Safety Town? Safety Town is a fun four-day safety awareness program that is designed for children entering kindergarten. Through the use of music, crafts, videos, books, community speakers and a child-sized town, the children are taught basic safety lessons that they will use for the rest of their lives.

The fee for Safety Town is $30 and covers the cost of the 4-day program, a bicycle helmet, and t-shirt.

Email *

Child's First Name *

Child's Last Name *

Street address: *

City: *

State: *

Zip Code: *

Child's Date of Birth: *

YYYY

School Attending in the Fall: *

Session Selection *

Morning Session (9a - 12p)

Afternoon Session (1p - 4p)

Morning Waiting List

Afternoon Waiting List

Child's T-shirt Size: *

Youth Small

Youth Medium

Youth Large

Youth XLarge

What is the primary language used in the home, regardless of the language spoken by the student? *

English

Spanish

Other:

What is the language most often spoken by the student? Note, we will do our best to accommodate language needs.
*

English

Spanish

Other:

Parent 1 Name (First and Last): *

Parent 1 Phone Number (Best number for contact during Safety Town session- home, work, or cell) *

Parent 1 Email Address: *

Parent 2 Name (First and Last):

Parent 2 Phone Number (Best number for contact during Safety Town session- home, work, or cell)

Parent 2 Email Address:

Emergency Contact 1 Name (First and Last) *

Emergency Contact 1 Phone (Best number for contact during Safety Town session- home, work, or cell) *

Relationship to Participant *

Physician's Name: *

Physician's Phone Number: *

Dentist's Name: *

Dentist's Phone Number: *

Known Allergies of Participant: (mark NA if none) *

Other Health Concerns:

Current Medications:

Child Release Person 1 (This is a person who is allowed to pick up your child. You will need to provide a signature authorizing this individual to pick up your child. Mark NA if no one else is authorized to pick up your child other than parents listed above.) *

Child Release Person 2 (This is a person who is allowed to pick up your child. You will need to provide a signature authorizing this individual to pick up your child. Mark NA if no one else is authorized to pick up your child other than parents listed above.) *

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