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2022 Safety Town Online Application

  1. Athens-Clarke County Police Department’s Safety Town Registration Form

    Please use one form per child

  2. Last Name, First Name

  3. Month/Date/Year

  4. Male / Female - Please Select One*
  5. Child Must Be Entering Kindergarten, Fall 2022


  6. Child's Address
  7. Last Name, First Name

  8. XXX-XXX-XXXX

  9. XXX-XXX-XXXX

  10. Emergency Contact Information (Person to contact if Parent/Guardian Cannot Be Reached)

    PLEASE NOTE: If your child will be picked up by someone other than the legal guardian, a signed note from the legal guardian must be provided to the program coordinators.  This note should indicate the name (listed below) and relationship to the child, as well as the duration of the pickup arrangements. Identification should be available upon request. 

  11. Last Name, First Name

  12. Grandparent, Family Friend, etc. 

  13. XXX-XXX-XXXX

  14. PLEASE NOTE: In case of emergency, we need your physician's name or the name of the doctor's office, as well as a phone number. 

  15. Physician's Name / Doctor's Name / Other Health Care Provider

  16. XXX-XXX-XXXX

  17. Please list any allergy/illness/disability that your child has or any other information that the Safety Town Staff needs to be aware of. If none, please type N/A or NONE.

  18. RELEASE OF LIABILITY / PHOTO RELEASE / MEDICAL TREATMENT RELEASE

    I hereby release and hold harmless the Athens-Clarke County Police Department and all of its employees, agents, and representatives from any and all claims, costs, damages, and liabilities for injuries sustained by my minor child’s participation in Safety Town. I further represent that my child is physically capable of participating in the program in which my child is enrolled. (Continued Below)

  19. Photo / Video Release*

    to the Athens-Clarke County Police Department to use digital photographs of my child in print and other media including the Athens-Clarke County Police Department’s web site, exclusively for promotion of the Athens-Clarke County Police Department programs. (Continued Below)

  20. Further, in case of an accident or serious illness, I authorize the staff of Safety Town to call the physician listed above for instructions or seek emergency medical assistance if deemed necessary.

  21. Leave This Blank:

  22. This field is not part of the form submission.