Safe Sitter

Grundy County Health Department

Safe at Home Student Registration Form
Tuesday, June 13 | 9:00 - 10:30 am

Grundy County Health Department

1716 Lincoln Street | Trenton, MO 64683

safesitter@grundycountyhealth.org

$5 class fee, snacks provided
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Phone Number*
Alternate Phone Number
Parent E-mail*
example@example.com
Snacks are provided, does your student have any food allergies we should be aware of?*

NoYes, please explain
Allergy information
Parent Information

Parent/Guardian please read and sign below.
- I will take all responsibility for deciding whether my child is capable and mature enough to stay home alone.
- The Registered Provider (GCHD) 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 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. for credentialing purposes. I understand that Safe Sitter, Inc. will not sell, share or trade this information with other organizations.
I AGREE with the Parent Information above.

AGREEDISAGREE
Signature*
Should be Empty:

Grundy County Health Department

Tuesday, June 13 | 9:00 - 10:30 am

Parent Information