Bainbridge-Auburn Safety Town

Registration Form

 Monday, July 10th - Friday, July 21st, 2017
 
Child's Name:
 *
Parent or Guardian:
 *
Address:
 *
Home Phone:
Cell Phone:
E-Mail Address:
 *
 (E-mail address is required for class time notification.)
 
Emergency Contact Name:
 *
Phone Number:
 *
Relationship to Child:
 *
  
Times: "1" first choice, "2" second choice
8:00 a.m. to 9:15 a.m.:
9:45 a.m. to 11:00 a.m.:
12:00 p.m. to 1:15 p.m.:
  
Does your child have any allergies or medical problems we should be aware of?
Allergies or Medical Problems:

 		*
If yes, please explain:
 We will not administer any medications.
 
 If you have any questions, e-mail us at the following: marconie@pd.bainbridgetwp.com or chief@pd.bainbridgetwp.com.
 
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