KATE MURRAY
DONALD X. CLAVIN JR.
SUPERVISOR
TOWN CLERK
1 WASHINGTON STREET HEMPSTEAD, NY 11550-4923
CHILD SAFETY IDENTIFICATION PROGRAM
Parental / Guardian Permission Form
Parent / Guardian:
First Name
Last Name
I ____________________, Hereby grant permission to allow my child / children to be nger printed
and photographed for the Town of Hempstead Child Safety Identication Kit.
Town
State
Zip Code
Tel #
Address:
Street
Apt #
REV. TC 1/20
Date:
Child:
First Name
Last Name
Child:
First Name
Last Name
Child:
First Name
Last Name
Child:
First Name
Last Name
Parent or Guardian
Signature of Parent or Guardian
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