Chautauqua Safety Village

Contact Information

Parent/Guardian Name

*

First Name

Last Name

Email

*

Phone

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

How many youth are you registering?

*

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:

Do you have a current Safety Village Membership?

*

Yes

No

Please select the day you are registering for	Quantity
$40 - June 27th, Superhero Day
$40 - June29th Camp Cretaceous
$40 - June 30th, Magic Camp

Please Select the day(s) you are registering for *	Quantity
$45 - June 27th, Superhero Day
$45 - June 29th, Camp Cretaceous
$45 - June 30th, Magic Camp

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 Note:

Your submission will not be finished until payment information has been completed. We use PayPal; however, you DO NOT need your own PayPal account to pay. You are able to use any credit card type that PayPal accepts. Once completed, you will receive an email confirmation. Please contact us with any questions. Thank you!