This is a FREE
Applications: Available at the Oberlin Police Department,
and The Oberlin Public Library
Registration deadline: Friday, June 3rd, 2011
Eligibility: Children who will enter Kindergarten this fall
Session 1 is June 13-17 th Monday-Friday
Session 2 is June 20-24 th Monday-Friday
Class Times: Morning Session 9:00 - 11:00 AM or
Afternoon Session 1:00 — 3:00 PM
Instructor: Lt. Kevin Scalli, Oberlin Police Dept.
Questions: Lt. Kevin Scalli, Oberlin Police Department
774-1061 or at firstname.lastname@example.org
CHILD'S NAME: ____________________________________________DATE OF BIRTH:________________________
PARENT/GUARDIAN'S NAME: ______________________________________________________________________
HOME PHONE: _________________________________ WORK PHONE:________________________________
PERSON TO CONTACT IF PARENT/GUARDIAN CANNOT BE REACHED:
NAME: _________________________________ RELATIONSHIP: _________________ PHONE: _________________
I would prefer that my child attend the (please check one Session and one Class type):
_____Session #1 (June 13-17) ______Session #2 (June 20-24)
_____ Morning class (9am-11am) ______Morning class (9am-11am)
_____ Afternoon class (1pm-3pm) ______Afternoon class (1pm-3pm)
May we photograph your child during Safety Town for submission to our
sponsors and local newspapers? YES NO
your child be coming from the
Does your child have any allergies (i.e., bee stings, food allergies, etc.)? YES NO
If so, please list_______________________________________________________________________
THE DEADLINE FOR REGISTRATION IS FRIDAY, JUNE 03, 2011
Please return this form to the Oberlin
Police Department or the
before June 03, 2011. Class size is limited, and registration is on a first-come, first-served basis.
Any questions may be directed to Lt. Kevin Scalli, Oberlin Police Dept., 774-1061.
You will be contacted to confirm your child’s enrollment session date and time.
permission for my child, __________________________, to participate in
its field trips, which may include; safety walks and school bus ride to/from the Oberlin Fire Station,
with the understanding that neither the Oberlin Police Department, City of Oberlin, Oberlin Schools or Oberlin Exchange Club is responsible for any accidents.
(Signature of parent/guardian) (Date)