Please print this form and submit it to the address below.

SafetyTown Application

Hi, my name is________________________________________

and I will be entering ()Kindergarten or ()1st Grade this Fall (Check one).

I would like to register for Safety Town. I have indicated below the class I would like

to participate in. I understand a confirmation of my registration will be mailed to me after

May 28th.

My address _________________________________________

__________________________________________________

Emergency contact & phone number(s)
___________________________________________________
Any special medical needs
___________________________________________________

Parent or Guardian Signature
___________________________________________________

Parent or Guardian Printed Name

Class dates (please indicate preferences by 1 or 2 , 1 being first choice)

June 12-June 23

July 10-July 21

____ 8 am- 10 am
____ 10:30 am -12:30 pm
____ 4:30 pm-6:30 pm

Registration fee enclosed (payable: Kiwanis Club of Richmond) $20.00

____ Additional tax deductible contribution to Safety Town

Mail registration to:

Safety Town
C/O Sara Cowan
1343 Liberty Ave.
Richmond, IN 47374

For questions call:

Misty Hollis at 765-962-2763 (Home)

or 765-935-1230 (Safety Village Office)

On behalf of our Honorary Chairman
we extend our sincere appreciation.

THANK YOU...for caring and sharing. and promoting...SAFETY FOR KIDS

--Bill Cosby