The Playsafe Registration is required each school year. There’s an administration fee of $25 per family due upon registration. Please be sure to complete this registration form before scheduling, and to thoroughly read the

dassa mckinney elem. (moniteau)

Playsafe is only available in the morning for Dassa McKinney Elementary school.

Slippery rock area elem. and moraine

PlaySafe Registration

Registration form for the 2024/2025 school year.

Choose Your School(Required)

Slippery Rock

Moraine

Dassa McKinney (Morning Only)

How Many Children Are You Registering?(Required)

1

2

3

Childs Name(Required)

First Last

Teacher(Required)

Grade(Required)

Allergies(Required)

Second Childs Name(Required)

First Last

Teacher(Required)

Grade(Required)

Allergies(Required)

Third Childs Name(Required)

First Last

Teacher(Required)

Grade(Required)

Allergies(Required)

Mother's Contact Information

Mothers Name(Required)

First Last

Email Address(Required)

Phone(Required)

Mother's Address(Required)

Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

Father's Contact Information

Same Address As Mother(Required)

Yes

No

Fathers Name(Required)

First Last

Email Address(Required)

Phone(Required)

Father's Address(Required)

Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

Pick-up Authorization

Please list at least two names, beside yourself, whom you authorize to pickup your child. If you are divorced, please list other parents name, if they are permitted to pickup your child. If there’s a court order involved, please provide a copy to the park office.

Name(Required)

First Last

Name(Required)

First Last

Name

First Last

Name

First Last

Emergency Contacts

Names of emergency contact if parent is unavailable.

Name(Required)

First Last

Phone(Required)

Name(Required)

First Last

Phone(Required)

Payment Details

Administration Fee(Required)

Price:

Fee

Coupon

Processing Fee

Price: $0.00

Total

Credit Card

Card Details

Cardholder Name

Cardholders Address(Required)

Same as Mother's AddressSame as Father's AddressDifferent Address

Enter The Cardholders Address

Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

You Must Agree To The Scheduling Terms At The Top Of The Form To Submit Your Information.

Name

This field is for validation purposes and should be left unchanged.