One moment please...
Registration Information
Parent/Guardian Name
*
First Name
Last Name
Email
*
Verify Email
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
How many youth are you registering?
*
select one
One
Two
Three
Four
Participating Youth Name
*
First Name
Last Name
Age
*
Second Youth Name
First Name
Last Name
Second Youth Age
Third Youth Name
First Name
Last Name
Third Youth Age
Fourth Youth Name
First Name
Last Name
Fourth Youth Age
Please list any allergies we should be aware of if applicable:
Would you like to be put our email list?
*
Yes please
No thanks
I am already on it
Photo Release
*
I give permission for my child to have his/her picture or video taken a the Chautauqua Children's Safety Education Village and to have these photos or videos as a part of a press release, on our website, in any media including Facebook, Instagram and other social media sites, on television, in videos created to display our classes for advertising purposes. I confirm that I am the legal parent or guardian of the child on this application form.
Yes
No
Please select the number of youth you are registering
*
Quantity
$45
-
Per Child
0
1
2
3
4
4
$40
-
For CSV Members
0
1
2
3
4
4
$25
-
Coupon Holder or Radio Listener Discount
0
1
2
3
4
5
6
7
8
9
10
10
Add 3% to my total amount to help cover the payment processing fees
