Safe Sitter

Grundy County Health Department

Safe Sitter Student Registration Form
Tuesday, August 9 | 9:00 am to 3:00 pm

Grundy County Health Department

1716 Lincoln Street | Trenton, MO 64683

safesitter@grundycountyhealth.org

$20 class fee, lunch provided
Student Name *

First Name Last Name
Birth Date *

Month Day Year
Gender
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Name *

First Name Last Name
Phone Number *
Alternate Phone Number
Parent E-mail *
example@example.com
Does the student have allergies such as foods or latex? *

No Yes, please explain
Allergy information
Manikin Practice

Safe Sitter® includes practice of rescue skills on CPR manikins. Manikins require strict standards for controlling infection.

I agree not to send my child if he/she has a contagious illness including rash.
I give permission for my child to practice on the manikins.
Mainikin Practice

YES, I AGREE with the above statement regarding manikin practice NO, I do NOT agree with the above statement regarding manikin practice
Parent Information

Parent/Guardian will sign waiver when student is dropped off for class.
- I will take all responsibility for deciding whether my child is capable and mature enough to babysit.
- I understand the importance of having my child attend each course session and arrive on time.
- The Registered Provider reserves the right to decline the application of any student, or send home any student who, according to the site's discretion, is disruptive or puts him/herself or others at risk.
- I, the undersigned, consent to the use, reproduction and publication by Safe Sitter, Inc. and/or the Registered Provider ofpictures or recordings taken of my child during the program for publicity purposes.
- I acknowledge and understand that there may be a risk of injury involved in the activities that my child will engage in during the program. In consideration of my child's participation in the program, I hereby agree to release, waive, hold harmless, and shall indemnify Safe Sitter, Inc. and the Registered Provider and their respective employees, members, officers and other staff members from liability to us and our child for any and all claims.
- I consent and authorize the Registered Provider to submit the name and address of my child to Safe Sitter, Inc. I understand that Safe Sitter, Inc. will not sell, share or trade this information with other organizations.
Should be Empty:

Grundy County Health Department

Tuesday, August 9 | 9:00 am to 3:00 pm

Parent Information