SAFETY CITY

*Please note that this is first come first serve basis and there is a limit to 30 students per class*

I, the undersigned parent/guardian, hereby grant permission for my child to participate in the Safety City program. I understand that Safety City aims to educate children on safety practices in an interactive environment. I also understand that PHOTOS will be taken and may be shared in a public forum and/ or further advertising. I further acknowledge that participation in the program involves physical activities and potential exposure to various safety scenarios.

PARENTAL REGISTRATION / CONSENT FORM & LIABILITY WAIVER

 

My signature below hereby acknowledges:

That my son/daughter and I are aware of the physical nature and possible risks of injury involved in taking this realistic and practical course in personal safety. That he/she is physically fit to participate in this course, involving various physical techniques; we realize that such techniques cannot be successfully employed in every situation; and proficiency can only be achieved through continued practice, exercise of good judgment, and a person's natural ability.

I also understand that sensitive subject matter will be discussed and is in the Parent's Manual for my review.

On behalf of my child and any other parent or legal guardian, my signature releases The City of Delphos, Ohio and its officers, employees, officials, volunteers, and agents, Delphos City Schools, Delphos St. Johns, and all other sponsors and their officers, employees, officials, and agents, from all liability for any injury or damage of any nature or kind that occurs during participation in, or as a result of participation in, this program, and I agree to hold harmless and indemnify the same from any liability for injury or damage of any kind that may be incurred as a result of this course or use of its strategies.

I HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND I SIGN IT VOLUNTARILY.

The initialing of this also grants permission for my child's picture to be taken for the purpose of the graduation certificate

and/or general media or press releases from the Delphos Safety City program.

In case of Emergency please contact:

2. Do you feel fine, without restriction?

3. Have you ever been hospitalized or treated for an injury?

4. Have you ever been injured and not received medical attention?

5. Do you have any current medical conditions for which you are currently being treated?

6. Are you currently using any prescription drugs?

7. Any known allergies, difficulty breathing, High blood pressure, or Diabetes

10. Are you or have you ever been involved in self-defense or Martial Arts

The above information is complete, true and accurate to the best of my knowledge.

After submitting this form please go to the Delphos City Schools website SRO page and complete the Safety City Scheduling form where you will select your preferred time to attend Safety City. Until both forms are submitted you are not completely registered.

https://www.delphoscityschools.org/district/school-resource-officer