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2019 AKRON SAFETY TOWN
Akron Safety Town is open to children:
*who reside in the City of Akron, and
*who are entering kindergarten or first grade
in the fall of 2019.
Akron Safety Town is a FREE, FUN, hands-on educational program
designed to teach young children about:
bicycle, bus, fire, playground, gun, dog, poison, stranger-danger,
calling 911, how to cross the street, and other safety issues.
Akron Safety Town sessions run for one week,
Monday through Friday, Breakfast starts at 8:30 Safety Town starts at 9:00 am – 12:00.
It is important to come EACH day!
Each child receives an Akron Safety Town t-shirt and a bicycle helmet.
June 3rd – 7th at Resnik CLC Community Learning Center
Address: 65 N. Meadowcroft Dr. Akron, Ohio 44313
June 10th – 14th at Findley Community Learning Center
Address: 65 W. Tallmadge Ave. Akron, Ohio 44310
(Sessions are on a FIRST-COME, FIRST-SERVED basis.)
To register, complete FULLY
ALL of the following forms.
Registrations may be turned in at your child’s CLC
until the end of the school year, or mailed to:
Akron After School
65 Steiner Ave.
Akron, OH 44301.
Akron Safety Town 2019 Registration Form and Emergency Instructions
Check which session you prefer: □ June 3rd -7th Resnik CLC or □ June 10th – 14th Findley CLC
Child’s Name:____________________________________________Date of Birth:_______________________
Home Address (complete mailing address, including city and ZIP code; no P.O. Boxes):
__________________________________________________________________________________________
The school your child will attend in Fall 2019:_____________________________________Grade:__________
Parent or Guardian’s Name:___________________________________________________________________
Home Phone:__________________________________Cell Phone:___________________________________
Email:______________________________________________@_____________________________________
Employer Name and Address __________________________________Work Phone:____________________
Second Parent or Guardian’s Name:____________________________________________________________
Home Phone:__________________________________Cell Phone:___________________________________
Email:______________________________________________@_____________________________________
Employer Name and Address __________________________________Work Phone:____________________
English-speaking contact (if you do not speak English on the phone):
Name:_______________________________________________Phone:________________________________
Pick-up Instructions
Please list 3 persons to whom your child may be released:
Name ____________________________________________ Phone __________________________________
Relationship to Child ________________________________________________________________________
Name ____________________________________________ Phone __________________________________
Relationship to Child ________________________________________________________________________
Name ____________________________________________ Phone __________________________________
Relationship to Child ________________________________________________________________________
ALL PERSONS, including parents, are required to show a picture ID when picking up children. No child will be released to anyone not listed on this form.
Children must be picked up, and are not allowed to leave by themselves and walk home.
For office use only: Date received: _______________ Rec’d by: ___________________
Akron Safety Town
Health Information
Physician: Dentist:
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Name
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Name
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Address
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Address
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City, State, ZIP
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City, State, ZIP
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Phone
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Phone
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Chronic Physical/Mental/Emotional Challenges (illness, condition, or special need which may have an impact at Safety Town):
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Allergies and Treatment:
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Medications:
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Food Allergies and Treatment:
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I DO give consent for emergency medical or dental treatment of my child.
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I DO NOT give consent for emergency medical or dental treatment of my child.
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Parent Signature_________________________________ Date______________________
Release of Liability—No changes to this release will be accepted
I, parent/guardian of ______________________________________, for myself and for my minor child, do hereby fully release and forever discharge Akron Safety Town, Akron Police Department, Akron Fire Department, Akron Public Schools, Fairlawn-West United Church of Christ, all Akron Safety Town locations, Director, Officer, Organizer, Supervisor, Akron Safety Town staff and volunteers, and guest participants from any and all claims for injuries, damages, or loss that my minor child or I may have (or which may occur to me or my minor child) arising out of participation in the Akron Safety Town activities in which I have enrolled my minor child. I further agree to indemnify and defend against any such claims.
Photographs are taken for local news and print media, as well as for Akron Safety Town publications. I understand that my minor child may be photographed or videotaped during Akron Safety Town for publicity or educational purposes.
I have read and fully understand this Akron Safety Town Release of Liability.
Parent/Guardian signature: ___________________________________Date:_______________
GASP, Guardians Advocating Child Safety and Protection, is in its 10th year serving the community to help provide a safer environment for our children by delivering safety programs to protect them from dangerous situations, sex offenses, abuse and abduction. We believe that Education + Prevention = Child Protection.
Our Fingerprint/ID events are provided free of charge for everyone throughout our community and beyond. We are now partnering with many local police and school systems at their Safety Town programs. GASP will provide the parents with an information sheet that they need to fill out with their child's pertinent information. All the information is then inputted into the computer. GASP volunteers then take 2 photos, a front view and a side view of their ear (everyone's ears are different), digital fingerprints, and a short video where we ask their name, age, and a few other questions, so we can get their voice.
All this information is then put on a disc. Once the disc is done, the parent and only the parent will have the disc and all the information. WE DO NOT KEEP ANY INFORMATION; NOTHING IS SAVED! Along with the disc, the parent will receive a bag with a DNA kit and other safety information and tips. We recommend the parent have a new disc updated every year since children grow, change, and may have new information.
The disc can be opened on their home computer and they can watch the video. They can also print out part of the disc and make their own ID card.
Thank you very much for caring about our children's safety!
Sincerely,
GASP
53 University Avenue 14th Floor I Akron, Ohio 44308 1.330.247.1402 I office@gasp123.org www.gaspohio.org
Child’s first name___________________________________________________________________________
Middle name______________________________________________________________________________
Last Name_________________________________________________________________________________
Nickname_________________________________________________________________________________
Parent/Guardian name______________________________________________________________________
Child’s gender_____________________________________________________________________________
Height___________________________________________________________________________________
Weight___________________________________________________________________________________
Eye color_________________________________________________________________________________
Hair color_________________________________________________________________________________
Glasses___________________________________________________________________________________
Race_____________________________________________________________________________________
Date of birth_______________________________________________________________________________
Distinguishing marks_________________________________________________________________________
Other health considerations___________________________________________________________________
Primary phone number_______________________________________________________________________
Address___________________________________________________________________________________
City______________________________________________ State__________________ Zip_______________