BRIGHTON SAFETY TOWN TEEN APPLICATION
*Applicant's Name
*Address
*City
*Zip Code
In Case of Emergency we should call:
* Name
*Phone Number
I GRANT MY PERMISSION FOR MY SON/DAUGHTER TO PARTICIPATE IN ALL
ACTIVITIES RELATED TO THE SAFETY TOWN PROGRAM, INCLUDING A BUS FIELD
TRIP. I HEREBY UNDERSTAND AND AGREE THAT I SHALL NOT, IN ANYWAY, HOLD
THE BRIGHTON SAFETY TOWN INC., AND ANY OF THE SAFETY TOWN STAFF
RESPONSIBLE FOR ANY INJURIES OR ACCIDENTS THAT MIGHT OCCUR TO MY
SON/DAUGHTER WHILE ASSISTING AT THE BRIGHTON SAFETY TOWN.
* Home Phone Number
* Parent Signature
PLEASE SPECIFY YOUR 1ST AND 2ND CHOICE
Please place number in box to indicate your choice!
June 25- June 29        9am-1pm       

July 9- July 13            9am-1pm

July 16- July 20          9am-1pm
Please schedule me with my friend:
Friend's Name
*Email address
Is this for community service hours?

If yes, then for what organization.
SAFETY TOWN IS A ONE WEEK PROGRAM AND IT'S IMPORTANT THAT YOU COMMIT
YOURSELF TO THE ENTIRE WEEK. THE YOUNGER CHILDREN BECOME VERY
ATTACHED TO OUR TEEN INSTRUCTORS AND SOMETIMES IT BECOMES A
PROBLEM WHEN THEIR INSTRUCTOR IS NOT THERE. WE WOULD LIKE TO KEEP
ABSENTEEISM TO A MINIMUM. WE DO TRY TO MAKE THIS A FUN EXPERIENCE FOR
OUR TEENS AS WELL AS OUR YOUNGER CHILDREN. IT WOULD BE
APPROXIMATELY A 4 1/2 HOUR COMMITMENT A DAY. IF YOU HAVE ANY QUESTIONS
OR CONCERNS, PLEASE FEEL FREE TO CONTACT ME:

Keri Monstrola - brightonsafetytown@yahoo.com
If needed - call 810-229-5731