Safety Town Registration 2019

If using this method, please contact the Carr Center with credit card information, or mail a check to:
The Carr Center , 1035 Beverly Ave., Zanesville, Ohio 43701
Cost is a $35 Donation

* Indicates required field

Child's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Birthdate *

M/F *

Primary Guardian *

First

Last

Home Number *

Cell Number *

Email *

Emergency Contact: The following people can be contacted in case of an emergency and serve as people my child may be released to.

Name *

First

Last

Phone Number *

Relationship *

Name *

First

Last

Phone Number *

Relationship *

In the even of an emergency *

Physician's Name *

Dentist's Name *

Known allergies of participant *

Choose One *

June 3 - 7 Coburn United Methodist Church June 10 - 14 Coburn United Methodist Church June 24 - 28 Trinity Evangelical Lutheran Church

Use of Photograph

Current Medications *

Health Concerns or Physical Impairments *

I hereby grant and give The Carr Center the right to use the participant's image for any and all purposed including, but not limited to, private or public presentations, advertising, publicity and promotion relating hereto.

Signature of Legal Guardian *

Liability Form

I acknowledge that participation in The Carr Center Safety Town Program may involve some risk of physical injury due to the nature of activities. In consideration for acceptance of these programs, I do hereby release and forever discharge, for myself, my heirs, executors and administrators, any and all claims to collect damages which my child may incur in these activities, and any and all rights to such damages against The Carr Center or its representatives, employees, independent contractors, agents or officials, directors, sponsors or any officials of these programs. I further represent that my child is in good physical condition to participate in this program.

Signature of Legal Guardian *

Your child will be placed in color groups. Participants are NOT guaranteed placement into the same color groups as siblings and friends, but we will try to accommodate as best as we can.

Comment *

Submit

Safety Town registeration