SAFETY TOWN REGISTRATION FORM

CHILD’S NAME______________________________________________________________________________________

                                                    (LAST)                                                   (FIRST)                                                                (MIDDLE)

                                PLEASE PRINT NAME AS YOU WOULD LIKE IT TO APPEAR ON HIS/HER NAME TAG

STREET ADDRESS__________________________________________________________________________________

PARENT/GUARDIAN_________________________________________________________________________________

PHONE NUMBER (WORK)_______________________________(HOME)_____________________________________

FAMILY PHYSICIAN_____________________________________(PHONE)_____________________________________

CHILD’S BIRTH DATE_________________________________MALE OR FEMALE_____________________________

EMERGENCY CONTACT___________________________________(PHONE)___________________________________

    & RELATIONSHIP

PLEASE LIST ANY HEALTH CONCERNS (ALLERGIES, ASTHMA, ETC.)_____________________________________

___________________________________________________________________________________________________

PLEASE CHECK ONE OF THE FOLLOWING:

______________________MORNING SESSION PREFERRED  ______________________EITHER SESSION IS OK

______________________AFTERNOON SESSION PREFERRED

Please indicate if there is a sibling or a friend you would like your child grouped with:_____________________________

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PLEASE RETURN THE ABOVE PORTION OF THIS FORM

SAFETY TOWN IS OPEN TO ALL CHILDREN ENTERING KINDERGARTEN THIS FALL AND WILL BE HELD

JUNE 16^TH THROUGH JUNE 27th,  2007.

WHERE:                                               Waller School, 195 Gardner Avenue, Burlington

MORNING SESSION:                            9:30 TO 11:30 AM

AFTERNOON SESSION:                        12:30 TO 2:30 PM

REGISTRATION FEE:                            $30.00

                                                                **Registration fee must accompany this registration form.  If you are requesting that                                                                                                your child be grouped with a sibling or a friend, please send both forms and checks together.**

REGISTRATION DEADLINE:                  JUNE 6, 2007

**Please send this registration form, consent form, and a self-addressed stamped envelope along with a check or money order payable to “BURLINGTON JAYCEES SAFETY TOWN” to Safety Town, Burlington Jaycees, P.O. Box 312, Burlington, WI  53105.

Sessions are limited to 60 children in each class.  After the registration deadline we will notify you as to which class your child will be attending.  If classes become filled your check will be returned to you.

Registration fees will not be refunded after Safety Town begins.  If your child is unable to attend, please contact Kathy Szmanda at 763-7188 no later than June 12^th.

Safety Town T-shirts will be available to purchase on the first day of class as well as throughout the program.  T-shirts are not required.

Thank You,

BURLINGTON JAYCEES

SAFTEY TOWN CONSENT FORM

CHILD’S NAME   _____________________________________________

                                             (Last)                                      (First)                     (Middle)

ADDRESS____________________________________________________

PHONE NUMBER_____________________________________________

                                                                (Home)                                   (Work)                                   (Other)

I HEREBY GIVE MY CONSENT FOR MY CHILD,_________________________________

TO PARTICIPATE IN THE “SAFETY TOWN” PROGRAM SPONSORED BY THE BURLINGTON JAYCEES.

I FURTHERMORE RELEASE THE SAID ORGANIZATION FOR ANY INJURIES RECEIVED BY ME SON/DAUGHTER FORM PARTICIPATING IN THE “SAFETY TOWN” PROGRAM.

EACH SESSION WILL BE LIMITED TO APPROXIMATELY 60 CHILDREN THAT WILL BE ENTERING KINDERGARTEN THIS FALL.

IF SOMEONE OTHER THAN A PARENT IS RESPONSIBLE FOR PICKING UP YOUR CHILD, PLEASE SEND A NOTE INDICATING THE ARRANGEMENTS YOU HAVE MADE ALONG WITH A PHONE NUMBER OF THAT PERSON.

IF WE DO NOT HAVE THIS SIGNED CONSENT FORM, YOUR CHILD WILL NOT BE ALLOWED TO PARTICIPATE IN THIS PROGRAM.

_____________________________________________

(Parent Signature is Required)