City Safesitter Registration Form

City Safesitter Registration Form

Class Date
Format: 05/12/2017
Student Name

Birth Date*
Format: 05/12/2017
*Student must be at least 11 years old
Name Student wants to be called in class:
Phone (Home)
Parent/Guardian Cell
Phone (work)
Parent/Guardian Email

Dear Parent/Guardian(s):

A great deal of information is presented in a short period of time during the Safe Sitter®class. We want every child to succeed in the class, and we will work with you to make alternate plans if your child has difficulty keeping up. Please let us know if there is anything about your child that we should know to help your child succeed in 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 class session and arrive on time.

Does your child have any allergies such as foods or latex?
Manikin Practice
Safe Sitter® class includes practice of rescue skills on CPR manikins. Manikins require strict standards for controlling infection
I agree not to send my child to class if he/she has a contagious illness including rash.
I give permission for my son/daughter to practice on the manikins.

  Emergency Medical Permission
In the event of a health emergency, I authorize (site)
to seek emergency care for
my child. My preferred hospital is:
. In the event of any accident or health
problem which may require the attention of a physician, I may be contacted at
If I am not available,
may be contacted at (phone)
and is authorized to act on behalf of my child.

Other Terms and Conditions
  •  The teaching site 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 teaching site of pictures or recordings taken of my child during the program for publicity purposes.
  • Acknowledgment of Risk of Injury/Release and Waiver. 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 teaching site and their respective employees, members, officers and other staff members from liability to us and our child for any and all claims.
  • I, the undersigned, have read this release and understand all of its items. I execute it voluntarily and with full knowledge of its meaning and significance.
  • I, the undersigned, hereby certify that to the best of my knowledge, my child is able to safely participate in the program activities for which he or she has been registered.
  • By submitting this registration form I agree to the terms listed above andprovide my signature as proof of acceptance.
  • I consent and authorize
 (site) to submit the name of my child
         to Safe Sitter, Inc.  I understand that Safe Sitter, Inc. will not sell, share or trade this information
        with other organizations.