Summer Playsafe

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Child's Name
Age
Please list an medical concerns or food allergies.
T-shirt Size
Second Child's Name
Child # 2 Age
Child #2 T-shirt Size
Please list an medical concerns or food allergies.
Mother/Legal Guardian Name
Mother/Legal Guardian Address:
Mother Phone/cell number
Mother E-Mail:
Father/Legal Guardian Name
Father/Legal Guardian Address:
Father Cell phone:
Father E-mail:
Please list at least two names, besides yourself, whom you authorize to pick-up your child.
1. Name:
2. Name:
1. Full Name and Number
2. Full Name and Number
The Park will not be responsible for any toys, hand held games or personal belongings your child/children brings to PlaySafe.
My child/children and I agree to abide by the Park's rules and regulations in order to maintain the safety and security of this program.

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