320 North Main Street Slippery Rock, PA 16057 Monday – Friday 8:00am-3:30pm

Summer Playsafe

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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