HUNTERSVILLE POLICE

DEPARTMENT
102 Gilead Road P.O. Box 664 Huntersville, N.C. 28070
(704) 875-6542 Fax (704) 875-2815
Philip K. Potter, CLEE
Chief of Police

$50.00 Registration Fee

Checks payable to: Town of Huntersville
Memo Section: Safety Town
All applications must be dropped off at the Police Department on or after March 14th

NAME:

Elementary School attending 2011

DATE OF BIRTH: AGE: SEX:

HOME ADDRESS:

PHONE:

CITY: STATE: ZIP:

PARENT/GUARDIAN INFORMATION:

MOTHER: FATHER:
PLACE OF EMPLOYMENT: PLACE OF EMPLOYMENT:

WORK PHONE: WORK PHONE:

CELL PHONE: CELL PHONE:

EMAIL: EMAIL:
EMERGENCY CONTACT INFORMATION:

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NAME: PHONE: RELATIONSHIP:

HEALTH INFORMATION:

ALLERGIES:

MEDICATIONS:

OTHER CONDITIONS:
Anyone that they would like to be paired
ANY OTHER SPECIAL NEEDS OR with?
CONCERNS?

AUTHORIZATION TO PICKUP:

The following persons have your permission to pick up your child. They must know the
password for your child and should be prepared to show an I.D. We will not dismiss your child
to any persons who are not on this list.

NAME: PHONE: RELATIONSHIP:

NAME: PHONE: RELATIONSHIP:

PASSWORD:

REGISTRATION – PLEASE CHECK WHICH SESSION YOU WOULD LIKE TO SIGN UP FOR
IN ORDER OF PREFERENCE STARTING WITH 1 FOR FIRST CHOICE THROUGH 6.

______Session #1 JUNE 13th – JUNE 16th 9:00a.m. -- 12:00p.m.

______ Session #2 JUNE 13th – JUNE 16th 1:00p.m. -- 4:00p.m.

______ Session #3 JUNE 20th – JUNE 23rd 9:00a.m. -- 12:00p.m.

______ Session #4 JUNE 20th – JUNE 23rd 1:00p.m. -- 4:00p.m.

______ Session #5 JUNE 27th – JUNE 30th 9:00a.m. -- 12:00p.m.

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______ Session #6 JUNE 27th – JUNE 30th 1:00p.m. -- 4:00p.m.

WAIVER:

I/We, ______________________________________, parents/guardians of _______________________

for myself/ourselves and on behalf of said minor child and his/her heirs, executors, administrators, or
assigns, hereby covenant and agree as follows:

To waive for all parties noted above all claims, demands, actions, or causes of action, against the City
of Huntersville, its Officers, agents and employees, of whatever kind or nature which may arise in any
manner by such reason of injury to person or property or both while such child is participating in the
Safety Town Program.

To never instigate any suit or action against the City of Huntersville, its Officers, agents, or employees
for damages, loss or injury of any kind for or on account of injury to said minor child’s person or
property or both which may arise in any manner while he/she is participating in this program.

Photographs, films, and recordings are sometimes made of the participants of the Safety Town
Program for class pictures, news releases, and other documentary purposes. I hereby authorize the
use of my child’s picture to be used in any non-commercial manner by any radio, television,
newspaper, City of Huntersville, or other Officers, agents, and employees of the Safety Town
Program.

By this enrollment of my child in this program sponsored by Huntersville Police Department, I certify
that I have disclosed to the town of Huntersville any restrictions or conditions that may hinder my
child’s participation in this program. In signing this waiver, I also give my permission for my child to
participate in all activities associated with this program, including those activities/field trips requiring
or involving transportation.

I furthermore hereby release, discharge and hold harmless the Town of Huntersville, its employees,
volunteers, instructors, and contractors from all actions, claims, demands, and costs for any injury or
illness my child may suffer as a result of his/her participations in this program and associated
activities.

I/We have read the foregoing waiver and covenant and understand that it constitutes a formal legal
document.

By my/our signature(s), I/We give consent for the above listed minor child to participate in the Safety
Town Program for the year of 2010.

________________________________________ _________________________________
Parent/Guardian Signature Date

________________________________________ _________________________________

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Parent/Guardian Signature Date

* Honor * Professionalism * Dedication *