REGISTRATION | My Site

Child's First Name

Child's Last Name

Prefered Name (if different from above)

Birthday

Month

Day

Year

Email

Cell Phone

Gender

Male

Female

Prefer Not To Say

Address (Street, City, State, Zip Code)

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

What phone number should we teach your child at Safety Town?

Emergency Contact Name & Number (If different from above

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship to Child

Medical Information

List any medical issues, allergies, medications, physical handicaps, etc. your child may present with

Physician/Clinic for your child

Physician/Clinic Phone #

Authorized PIck-Up List

(Any persons authorized to pick up your child must be listed here- this includes additional parents, grandparents, nannies/babysitters, friends, parents of another child attending, etc)

Name

Phone

Name

Phone

Name

Phone

What school will your child attend in the Fall?

What grade will your child enter in the Fall?

Is there anything else we should know about your child?

Parent/Guardian Signature

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In consideration of this application to participate in Safety Town, All participants, intending to be legally bound hereby, for myself, my heirs, executors and administrators, waive and release Safety Town Northwest Arkansas, Lisa Academy and any and all sponsors and representatives, successors, and assigns from any and all rights and claims for damages my child may have arising out of any injuries and illnesses suffered in this event.

Signature

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I authorize staff to administer basic first aid if needed

Parent/Guardian Signature

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I hereby give my consent for the above mentioned child to be photographed at Safety Town. I also agree that they may use or permit others to use the negatives or prints in such a manner as they deem necessary.

***PAYMENT - when redirected to the following page, select payment method under Express Checkout at the top of the page first (otherwise your payment will not go through and registration will be rejected)

$125

June 8 - 11, 2026 | 9:00am - 12:00 pm

Northwest Arkansas

Safety Town Student Registration: Now Open

Children born between June 2019 - June 2021 are eligible to attend

June 8 - 11, 2026 | 9:00am - 12:00 pm

Safety Town Student Registration: Now Open Children born between June 2019 - June 2021 are eligible to attend

Safety Town Student Registration: Now Open

Children born between June 2019 - June 2021 are eligible to attend