Safety Town Student Reservation 2022
What is Safety Town? Safety Town is a fun five-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.
Sign in to Google to save your progress. Learn more
Email *
Child's First Name *
Child's Last Name *
Street address: *
City: *
State: *
Zip Code: *
Child's Date of Birth: *
MM
/
DD
/
YYYY
School Attending in the Fall: *
Session Selection *
Required
Child's T-shirt Size: *
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.) *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Union County Health Department. Report Abuse