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2. Child's Name:*
3. Birth Date:*
4. Age:*
6. Gender:*

   1. Female
   2. Male
7. Grade Entering:*

   1. Kindergarten
   2. First Grade
   3. Other
8. School:*
10. Related Services: *

    Does your child receive special instruction or related services at their school?

    1. Yes
    2. No
11. Other comments:
13. Sessions:

    Please choose a first and second choice in case your first choice is not available. There will also be a session from 9:30 a.m. to noon on Friday, June 9, and Friday, June 16, for students with special needs.

15. First Choice Date and Time:*

    1. June 5 - 8 from 9 to 11 a.m.
    2. June 5 - 8 from 1 to 3 p.m.
    3. June 12 - 15 from 9 to 11 a.m.
    4. June 12 - 15 from 1 to 3 p.m.
    5. Special Needs: June 9 from 9 a.m. to Noon
    6. Special Needs: June 16 from 9 a.m. to Noon
16. Second Choice Date and Time: *

    1. June 5 - 8 from 9 to 11 a.m.
    2. June 5 - 8 from 1 to 3 p.m.
    3. June 12 - 15 from 9 to 11 a.m.
    4. June 12 - 15 from 1 to 3 p.m.
    5. Special Needs: June 9 from 9 a.m. to Noon
    6. Special Needs: June 16 from 9 a.m. to Noon
18. Address:*
19. City:*
20. State:*
21. Zip:*
23. Parent/Guardian's Name:*
24. Primary Phone:*
25. Alternate Phone:*
27. Email: *
28. Shirt Size:*

    1. Child XS
    2. Child S
    3. Child M
    4. Child L
    5. Adult S
    6. Adult M
    7. Adult L
    8. Adult XL
30. Emergency Contact Information

    Parent/Guardian listed above will be contacted first.

32. Name:*
33. Phone:*
34. Relationship:*
36. Name:*
37. Phone:*
38. Relationship:*

40. Consent to Treat:

    In the event I cannot be reached in an emergency, such as accident or serious illness, I hereby give permission to the Safety Town staff to seek emergency medical assistance for my child named above.

    Release of Liability:

    I hereby, for myself, my child, my heirs, executors and administrators, waiver and release any and all rights and claims for damages I or my child may have or may acquire in the future against the City of Beavercreek and its employees/representatives, successors and assigns for any and all injuries suffered by myself or my child in connection with the said program(s). For the consideration stated above, I further agree that in the event that my child repudiates or attempts to repudiate such release, I will personally indemnify and save harmless the City of Beavercreek, its successors and assigns, for any and all loss and damage occasioned thereby.

    Photo Release:

    I do hereby grant and give the City of Beavercreek the right to use my or my child’s photograph or image without my child’s name, both singly and in conjunction with other persons or objects and presentations, advertising, publicity, and promotion relating thereto. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold the City of Beavercreek and its employees/representatives, successors and assign harmless of and from any and all liability of whatever nature that might arise out of or result from such program(s).

42. Photo Release:*

    Do you agree to allow the City of Beavercreek Police Department the right to use this child’s photograph? Names will not be included.

    1. Yes
    2. No
44. Signature of Parent/Guardian:*

    By typing your full name, you affirm all information provided in this application is true and accurate. You also agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

45. Relationship:*
47. Authorization:

    Authorized to pick up, including parent/guardian: (proper ID may be required)

49. Name:*
50. Relationship:*
52. Name:*
53. Relationship:*
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field