SAFETY TOWN
REGISTRATION FORM

CHILD'S INFORMATION

Legal First Name

Legal Last Name

Name to be used on their name tag

Date of Birth
(mm/dd/yyyy)

Female

Male

Small
(6-8)

Medium
(10-12)

Large
(14-16)

X-Large
(Adult Small)

Street Address:

City:

State:

Zip:

County:

Phone:

Elementary School:
(next school year)

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25% of survey complete.