Sheboygan County Safety Town Sponsored by the Sheboygan Service Club
An officially registered, accredited and certified program under National Safety Town Center
Email address *
SSC
Dear Volunteer and Parent/Guardian:
Please fill out this form to be scheduled for your chosen Safety Town sessions! For questions regarding volunteering, please send an email to SSCSafetyTown@gmail.com

I have committed my time as a volunteer for the Sheboygan Safety Town.

First Name *
Your answer
Last Name *
Your answer
Student email address *
Your answer
Student phone number *
Your answer
School Attending *
Your answer
Grade that you will be entering in Fall of 2018 *
Your answer
Student Age *
Your answer
Session Date & Time Selections *
Required
PARENT/GUARDIAN PERMISSION
I realize the importance of this commitment and hereby give consent for my child to participate in the Safety Town program sponsored by the Sheboygan Service Club (SSC) and the Sheboygan Area Recreation Department. I grant permission for my child to go on any schedule field trips. I release SSC, it’s individual members, and those assisting with the program from all liabilities.
Parent/Guardian First & Last Name *
Your answer
Parent/Guardian email address *
Your answer
Parent/Guardian Phone Number *
Your answer
Emergency Contact Name & Phone Number *
Your answer
Certification of Signatures *
Required
PARENT/Guardian: By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
Your answer
Thank you!
Abby Yinko
2018 Sheboygan Service Club Safety Town Teen Volunteer Coordinator
920-698-1001
SSCSafetyTown@gmail.com

The NATIONAL SAFTEY TOWN CENTER is a non-profit, tax deductible, public supported organization to promote the importance of early childhood education.

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