Safety Town 2024 Student Registration

Safety Town Application:

School District	Host School
Big Walnut	*Big Walnut Intermediate School* 777 Cheshire Elementary School, Sunbury, OH 43074
Buckeye Valley	*Buckeye Valley Middle School* 683 Coover Road, Delaware, OH 43015
Olentangy	*Shale Meadows Elementary School* 4458 North Road, Lewis Center, OH 43035

All Olentangy Safety Town sessions and their waitlists are full.

"*" indicates required fields

Step 1 of 4 - Session Selection

Session Selection*

Applications for each session over the limit of 68 will be added to the waitlist for that session. Only register for one session. When sessions are full, they will disappear from the options list.

WAITLIST ONLY June 10-14 Big Walnut AM Session (8:00-10:30am)

WAITLIST ONLY June 10-14 Big Walnut PM Session (12:00-2:30pm)

June 24-28 Buckeye Valley AM Session (8:00-10:30am)

June 24-28 Buckeye Valley PM Session (12:00-2:30pm)

Child's Last Name*

Child's First Name*

Middle Initial

Name child goes by (if different from above)

Child's Shirt Size (Youth size)*

Child's Date of Birth*

Child is:

Male

Female

Address*

Street Address City State / Province / Region ZIP / Postal Code

Grade child will be entering:

Safety Town is only open to children entering kindergarten or 1st grade.

Kindergarten

1st Grade

School District child is/will be attending*

Other School District Name

BUCKEYE VALLEY RESIDENTS ONLY: Do you want your child to be bussed to and from Safety Town?*

Students who live in the Buckeye Valley School District have the option to be picked up and dropped off by the BVLS transportation department. Please select if you are interested in being bussed.

Yes

No or Not Applicable

Parent/Guardian's Last Name*

Parent/Guardian's First Name*

Parent/Guardian's Phone Number*

Parent/Guardian's Email Address*

Enter Email Confirm Email

Additional Parent/Guardian's Last Name

Additional Parent/Guardian's First Name

Additional contact number

Parent/Guardian's Address (if different from above)

Street Address City State / Province / Region ZIP / Postal Code

Child's NON-FOOD allergies/medical issues/special considerations/etc.(If none, type N/A)*

*No food is served at Safety Town, please do not include food allergies.

Child's Doctor's Name*

Doctor's Phone Number*

Emergency Contact Name (other than parent/guardian)*

Emergency Contact phone number*

LEGAL First & Last names of adult(s) (18+) authorized to pick child up from Safety Town*

Please include parent's names and group any common last names together. EX: Jane/John/Susan/Walter Doe, Alice/Robert Jenkins

Acknowledgement of Group Assignments*

I understand that children will be assigned to groups prior to the start of the program, and cannot be changed after they are assigned. We are not able to accommodate friend groupings.

I understand that no group preferences will be honored for this program.

Acknowledgement of Application and Waitlist Status*

Submitting this form is completion of the application. There will be a small number of applications accepted above the session limit to compile a waitlist. Entrance to the program is guaranteed on a first come, first serve basis, with residency verifications. Acceptance or waitlist status will be confirmed by 4/15/2024.

I understand that this completed application may be placed on the waitlist.

Acknowledgement and Release from Liability*

Please review the following acknowledgment and release. In consideration of the opportunity to participate in the activities (“Activity”) offered by the Delaware County Sheriff’s Office, the undersigned hereby agrees and states as follows: 1. My child is competent and physically able, capable, and qualified to participate in the Activity. 2. I agree to voluntarily allow his or her child to participate in the Activity entirely upon the undersigned’s own initiative, risk, and responsibility, and I acknowledge that there are inherent risks and dangers to the participant associated with the Activity. 3. I hereby acknowledge and certify that: a. That my child participates in the Activity at his/her own risk. b. I understand and agrees on behalf of himself/herself and his/her heirs, executors, administrators, successors or assigns, and any and all releasers, to forever waive, release, protect, indemnify, and hold completely harmless the organizers of this Activity, including, without limitation, Delaware County, the Delaware County Board of Commissioners, the Delaware County Sheriff, and all of their respective boards, departments, officials, officers, employees, representatives, agents, volunteers, servants, and/or other person or persons acting on behalf of such, from any and all claims, demands, actions or causes of action, on account of any injuries or damage to the undersigned or the undersigned’s personal property which may occur relating to participation in this Activity, whatever the source or nature, whether or not said harm or injury occurs through the misfeasance, malfeasance, negligence, recklessness, or unintentional conduct of any of the foregoing or for said harm or damage caused by the acts of a person or persons not employed by or associated with any of the foregoing. I, the undersigned, acknowledge that I have read, understand, and agree to all terms and conditions herein and fully accept the same and agree to be bound thereby. By clicking below, I am stating that I have read this acknowledgment and release by my own free will. *

I agree to all terms and conditions listed above

Photograph/Audio/Video Permission, Indemnification, Release & Waiver*

The undersigned hereby grants to the Board of Commissioners of Delaware County, Ohio, the Delaware County, Ohio Sheriff’s Office, Delaware County, Ohio, and their respective boards, officials, officers, designees, agents and assigns (collectively “County”), unlimited permission to use, publish and republish in any form or media, information about the undersigned and reproductions of the likeness and the voice (photographic, video recording, audio recording, or otherwise) of the undersigned, with or without identification of the undersigned by name (“Publication”). The undersigned agrees to indemnify and hold free and completely harmless the County from any and all actions, claims, suits, demands, judgments, damages, losses, costs, and expenses, including, but not limited to attorney’s fees, arising out of or resulting from Publication. Likewise, the undersigned agrees to waive and release the County from any and all claims, actions, causes of action, demands, and rights of any and all kinds whatsoever, which the undersigned has, may have, or which may accrue against the County and all of their respective successors or assigns from Publication. By clicking below you either consent or do not consent to the above statement

I consent (DCSO can take videos/photos of your child - names are NEVER published)

I do not consent (DCSO cannot take videos/photos of your child)