Safetyville Square Session E Registration Safetyville Square Session E 2024 Section Child’s Name * First Last * Last School grade student will be attending * Kindergarten 1st School * Date of Birth * Parent/Guardian Name * First Last * Last Parent/Guardian Phone * Make sure this is a number that can be reached during the class. Parent/Guardian Email * Parent/Guardian 2 Name Parent/Guardian 2 Name First First Last Last Parent/Guardian 2 Phone Address * Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip/Postal Zip/Postal Child’s Doctor * Doctor Phone * Photo Release * Yes No Do you consent to your child being photographed and for those photographs to be used for any legal use including but not limited to: publicity, copyright purposes, illustration, advertising, and web content? Where did you hear about Safetyville Square? Facebook Parent Square Flyer from School Friends/Family School Resource Officer Attended previously Kindergarten screening OtherOther Additional Information Please provide any additional information as to special needs, medical conditions, etc. that will assist us with your child. Method of Payment Credit CardPayPalCheck Registration not complete until payment is received. Total $ Non-refundable fee Payment Upon submission you will receive an ID number. Please include this number and your child’s name in the Memo section of your check. This is how we will verify your payment has been received. Please send your check to: Centerville Noon Optimist Club P.O. Box 750492 Dayton, OH 45475-0492 Upon submission you will be redirected to PayPal’s website to complete your payment. As a reminder your registration is not considered complete until your payment is received. By signing this form, you consent to your child’s participation in the Mark A. Kreusch Safetyville Square and agree to pay a nonrefundable fee of $40. Parent/Guardian Signature * signature keyboard Clear Captcha Hidden Source OnlineGuestManual Email 2 Item Name Payment Status Value Not SetCompletedFailedCancelled RefundedCancelled No RefundComplementary Registration Status ActiveCanceledMoved to another session Notes If you are human, leave this field blank. Submit Δ
