Safety Village Registration Form

Child's Name *

First Name Last Name

Child's Gender

Parent/Guardian #1 *

First Name Last Name

Parent/Guardian #2

First Name Last Name

E-mail (all communication will be sent via email) *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Cell phone number will be used for teaching purposes.

Home Phone Number

Area Code Phone Number

Cell Phone Number *

Area Code Phone Number

How did you hear about the program?

Preschool currently attending, if any *

Kindergarten your child will be attending *

Please indicate any allergies or medical conditions of which we should be aware *

Please check all that apply

I am interested in participating as a volunteer during Safety Village I do not wish to have my child's picture used in local publications or the JWCS Facebook page Please do not share my contact information with this year's sponsor(s). (It will not be shared with any other entity).

To give consent for your child to participate in the Junior Woman's Club of Sparta Safety Village please choose yes below and add your signature (type your name) *

Yes, I give consent for my child to participate in Safety Village. No, I do not give my consent.

*

Parent/Guardian Signature (Type your name)

Payment options - choose one: *

Payment by check can be sent to:
JWCS
PO Box 626
Sparta, NJ 07871

Please submit your payment at www.jwcsparta.org/safety-village-payments. Child's place in the program can't be confirmed until both registration and payment are received.

Enter the message as it's shown *