RECEIPT
#________
SAFETY
CITY CLASS
ASSIGNMENT________
MAUMEE
POLICE DIVISION
REGISTRATION
FORM
CHILD'S NAME________________________________ NAME CHILD PREFERS
_____________________
DATE OF BIRTH_____________________________________ AGE _________ SEX _________
CHILD'S
ADDRESS_____________________________________________________________________
STREET CITY ZIP CODE
PARENT/GUARDIAN________________________________________HOME
PHONE___________________
CHILD WILL BE IN KINDERGARTEN AT _________________________SCHOOL
EMERGENCY INFORMATION:
***PERSONS TO BE CONTACTED IF PARENT CANNOT BE NOTIFIED
1. ____________________________
_________________________
_______________________
2. ____________________________
_________________________
_______________________
NAME RELATIONSHIP TO CHILD PHONE
CHILD'S DOCTOR____________________________________________ PHONE__________________
LIST ANY HANDICAP, ALLERGY, OR SPECIAL HEALTH CONDITION OF YOUR
CHILD_______________
____________________________________________________________________________________
____________________________________________________________________________________
DATES OF COURSES 8:00 A.M. TO 10:30 A.M.
11:30 A.M. TO 2:00 P.M.
JUNE 15-26 ( ) ( )
Registration Deadline June 11
JULY 6-JULY 17
( ) NO JULY PM SESSION
Registration Deadline June 30
Please indicate PREFERRED session with a (1), and ALTERNATE choice with
a (2) and (3).
DUE TO LIMITED ENROLLMENT, YOU ARE ENCOURAGED TO RETURN THE
REGISTRATION FORM AS SOON AS POSSIBLE AFTER APRIL 30TH, ALONG
WITH CASH OR CHECK PAYABLE TO "THE CITY OF MAUMEE". There is no
advantage to returning this form any sooner than April 30th.
COST: CITY OF MAUMEE RESIDENTS . . . . . . . . .
. . $20.00*
CHILDREN ATTENDING
MAUMEE SCHOOLS. . . . . . . $20.00
NON-RESIDENTS . . . . . . . . . . . . . . . . .$25.00
*CONSULT COVER LETTER FOR MAUMEE CITY BOUNDARIES
I hereby give my consent for my son/daughter to participate in the
Safety City Program and I understand that I am to provide the transportation to
and from Wayne Trail School.
SIGNED_________________________________
Please bring or mail this form to:
Safety City
Maumee Police Division
109 East Dudley Street
Maumee, OH 43537