Clone of Newton Safety Town Registration Form

Newton Safety Town Registration
Student Information
Student's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Cell Number
E-mail
example@example.com
Time Slot
Class Times(**We will hold a 1200-1400 ONLY if we have at least 12 students)
Medical Release and Authorization

I give my consent, after all reasonable attempts to contact me at phone number(s) provided have been unsuccessful, for: (1) The administration of any treatment deemed necessary by the physician or dentist specified (if any), or in the event the specified practitioner is not available or no practitioner has been specified, then by another licensed physician or dentist; and (2) The transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity for surgery are obtained in writing prior to the surgery.

The following information is needed by any hospital or practitioner not having access to the child's medical history:
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Additional Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Please list persons picking up or dropping off
Does the Student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the Student prescribed an inhaler? If yes, please explain any instructions.
Are there any physical limitations, impairments, or special considerations the Safety Town deputies should know about your child?
Media Authorization
I give the Miami County Sheriff’s Office and representatives of the Miami County Sheriff’s Office permission to use my child/children’s name, photo, image, or likeness for promotion of their Safety Town program and for use on social media and internet.

Yes, I give my consentNo, I do not give consent
Ident-a-Kid ID
Childs Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Child's Eye Color
Childs Height (in inches)
Child's Weight
T-Shirt Size
Confirmation

BY ACKNOWLEDGING BELOW I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty:

Newton Safety Town Registration

Student Information

Time Slot

Media Authorization

Ident-a-Kid ID