Safety Town Registration

Safety Town Registration

Parent's Name *

First Name

MI

Last

Address *

Street

Apt, floor, suite, etc.

City

State

Zip

Phone

E-mail

Child 1 Name *

First Name

MI

Last

Child 1 age on the first day of the selected session. *
Child 1 Date of Birth

Child 2 Name

First Name

MI

Last

Child 2 age on the first day of the selected session.
Child 2 Date of Birth

Child 3 Name

First Name

MI

Last

Child 3 age on the first day of the selected session.
Child 3 Date of Birth
Have any of these children previously attended Safety Town?
Please List the names of those who previously attended:
Does your child currently receive services from the Special School District? *
If so, please list the child's name:
Does your child have any other conditions requiring special services? *
If so, please list the child's name:
Is your child potty trained? *

Please indicate your preference of sessions that you wish for your child to attend by entering a number from 1 to 6 (1 being your first choice and 6 being your last choice) in the space underneath each session. If your child cannot attend a particular session write "NO" in the space provided.

SESSION 1: June 3 through June 14, 10:00 a.m. to 12:00 NOON *
SESSION 2: June 3 through June 14, 1:00 p.m. to 3:00 p.m. *
SESSION 3: June 17 through June 28, 10:00 a.m. to 12:00 NOON *
SESSION 4: June 17 through June 28, 1:00 p.m. to 3:00 p.m. *
SESSION 5: July 8 through July 19, 10:00 a.m. to 12:00 NOON *
SESSION 6: July 8 through July 19, 1:00 p.m. to 3:00 p.m. *
How did you hear about the Safety Town program? *

* YOU WILL BE NOTIFIED WITHIN TWO WEEKS BY MAIL IF YOUR CHILD IS ACCEPTED INTO THE SAFETY TOWN PROGRAM. UPON RECEIPT OF THIS NOTIFICATION A $30.00 FEE FOR SUPPLIES MUST BE RECEIVED BY MAY 20, 2024 TO COMPLETE YOUR REGISTRATION.

Date of Registration

Please type the above code