2017 Safety Town Participant Registration
  1. Safety Town will be offered this June 19th-23rd to 2017 incoming Marysville Exempted Village School District kindergartners! The program will be limited to 150 students this year and registration will be conducted on a first come, first served basis. Parents may register their child for either the morning session (9am-12pm) or the afternoon session (1pm-4pm). We will make every effort to place participants in their preferred session. However, due to limited space, we cannot guarantee that your child will be placed in your preferred session.
  2. Child's First Name(*)
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  3. Child's Last Name(*)
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  4. Street Address(*)
  5. City(*)
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  6. State(*)
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  7. Zip Code(*)
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  8. Child's Date of Birth(*)

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  9. Name of school child will attend this fall(*)
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  10. Child's Tshirt Size(*)
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  11. Preferred Session: We understand that your family may have special circumstances that would prevent your child from attending one of the sessions. We will make every effort to accommodate your needs. You will be notified by email of the session to which your child has been assigned.
  12. Parent 1 First Name(*)
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  13. Parent 1 Last Name(*)
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  14. Parent 1 Phone Number(*)
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  15. Parent 1 Email Address(*)
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  16. Parent 2 First Name
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  17. Parent 2 Last Name
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  18. Parent 2 Phone Number
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  19. Parent 2 Email Address
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  20. Please indicate your preferred session:(*)
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  21. Emergency Contacts: List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be local, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years old.
  22. Emergency Contact 1 Name(*)
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  23. Emergency Contact 1 Phone Number(*)
    Please enter in format: XXX-XXX-XXXX
  24. Relationship to Participant(*)
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  25. Emergency Contact 2 Name(*)
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  26. Emergency Contact 2 Phone Number(*)
    Please enter in format: XXX-XXX-XXXX
  27. Contact 2 Relationship to Participant(*)
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  28. Physician's Name
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  29. Physician's Phone
    Please enter in format: XXX-XXX-XXXX
  30. Dentist's Name
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  31. Dentist's Phone
    Please enter in format: XXX-XXX-XXXX
  32. Known allergies of child
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  33. Other health concerns
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  34. Current medications
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  35. Please sign the registration form by typing your full name(*)
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  36. Enter the Letter(*)
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