I pledge to provide a SafeHome.

I will provide adult supervision to all children visiting my home.

I will provide a secure storage place for all forms of alcohol, firearms and other                                                                   potentially hazardous items. 

I will not serve nor will I allow youth under the legal drinking age of 21 to consume                                                   alcohol in my home, or on my property.

I wish for communication with any parent who personally observes my child using                                               alcohol or other drugs.

I will communicate with any SafeHomes parent of a child I personally observe using                                                   alcohol or other drugs.

Parent/s Signature/s   ________________________________, ___________________________________

Parent's Name/s (please print) ___________________________,__________________________________

Email Address_____________________________@_______________________________

Student's Name/s________________________________ School ______________________________

Student's Name/s________________________________ School ______________________________

Student's Name/s________________________________ School ______________________________

Address____________________________________________________________________

Home Phone number/s________________________  Work Phone number/s__________________________

I give my permission to have my name and phone number included in the SafeHomes Directory._______

Print and return this form to: GIPTA Council, SafeHomes, District Ofc. 1100 Ransom Road, Grand Is. NY 14072