Brighton Safety Town Emergency Card
*Child's
Name
*Address
*City
*Zip Code
*Gender
*Birthday
*E-mail
Home Phone
Cell Phone
Emergency Contact #1
(Please insert the following
information below)
Name:
Address:
City:
Zip:
Phone Number:
Emergency Contact #2
(Please insert the following
information below)
Name:
Address:
City:
Zip:
Phone Number:
Please list below the people who have your permission to drop off or pick up
your child from safety town.

*Please include their full name and phone number*
Please list any allergies that your
child has, or any medical
information that we should be
aware of!
Additional Comments
Medical Information
*Doctor's Name
*Insurance Provider
*Contract Number
*Parents Signature
* Session
* Designates Required Field
Continue for payment information to secure your spot! :)
Teens- press submit to finalize your registration.
No payment needed! Thanks