Safety Town 2011 Registration 
Our 2011 Session is Currently Full.

Child’s Name:
Boy or Girl:
Parent’s Name:
E-mail:
Address:
City:
State:      Zip:
Home Phone:
Emergency Phone:
School child will attend for kindergarten:
Food allergies and/or other medical information:

Parent Release Form for Media Recording
I do hereby grant or deny permission to The Junior Charity League of Concord to use the image of my child as marked by my selections(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images.
Deny permission to use my child’s image at all.
Grant permission to use my child’s image in the following way:
Unrestricted Usage: I give unrestricted permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by The Junior Charity League of Concord for variety of purposes and that these images may be used without further notifying me. I do understand that the child’s last name will not be used in conjunction with any video or digital images.