2019 Cuyahoga Heights PTO Safety Town Registration
Cuyahoga Heights Elementary
4880 East 71st Street
Cuyahoga Heights, OH 44125
(216)429-5834
mwilliams@cuyhts.org
Monday through Friday, June 10-21, 2019 9:00 a.m. - 11:00 a.m.
Child's First Name *
Your answer
Child's Last Name *
Your answer
Age *
Date of Birth (Must be 5 or older by Aug 1, 2019) *
MM
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DD
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Gender
Current Grade Level *
Child's Street *
Your answer
Child's City *
Your answer
Child's State *
Your answer
Child's Zip *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone #1 *
Your answer
Parent/Guardian Phone #2 *
Your answer
Parent/Guardian Email Address #1
Your answer
Parent/Guardian Email Address #2
Your answer
Doctor Name *
Your answer
Doctor Phone *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
Please list child's medical conditions/allergies
Your answer
Release of Liability *
Required
Photography Consent *
Payment *
Required
Does your child need a helmet? *
T-shirt size (Shirt is included in registration fee.) *
Electronic Signature *
Required
Signed *
Type your name
Your answer
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