SAFETY CAMP REGISTRATION

GET REGISTERED FOR SAFETY CAMP!

Please complete the form below and submit to register your child(ren).

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Child

Child's Information

Full Name: *

First and Last Names

Gender: *

Gender of Child

Male

Female

Date of Birth: *

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Child's date of birth.

Age: *

Age of child.

Address of Child: *

Child's address.

Parent/Guardian Contact Information:

Contact information for parent or guardian of child.

Full Name: *

Please provide full name of parent or guardian.

Email *

Please provide an email address where we can send camp information.

Home Address:

Provide home address of parent or guardian if different from child.

Phone Number: *

Provide best number to contact parent or guardian.

Additional Emergency Contacts: *

Please list any additional emergency contact information, including names and phone numbers, and/or parents/guardians who are permitted to pick up your child if applicable.

Medical Information:

Provide any relevant information we need to know regarding your child's health.

List any medical concerns and/or medications:

Please provide information regarding any medical concerns for your child, including any medications if needed.

Allergies or dietary restrictions:

Please list any allergies or dietary restrictions, including any requiring medication.

Photo Release: *

I hereby give permission for my child to be photographed during the 2024 Safety Camp. I understand the photos may be used for promotional purposes by the Grand Rapids Police Department/Itasca County Sheriff's Office and its affiliates.

YES

NO (I deny permission for my child's photo to be taken.)