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Please use one form per child
Last Name, First Name
Child Must Be Entering Kindergarten, Fall 2022
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.
Grandparent, Family Friend, etc.
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.
Physician's Name / Doctor's Name / Other Health Care Provider
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.
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)
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)
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.
This field is not part of the form submission.
* indicates a required field