Bainbridge-Auburn Safety Town

Registration Form

 Monday, June 18th - Friday, June 29th, 2018
Child's Name:
Parent or Guardian:
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: or
Please enter the code shown above in the box below:

*  Required