Safe Sitter® Registration Form
Student Name
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Name student wants to be called
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Gender
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Grade
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Date of Birth
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Parent/Guardian Name
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Parent Email
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Parent Email needs to be a valid email address.
Parent Cell Phone
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Work Phone
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Secondary Phone
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Address
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City
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State
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Zip
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Dear Parent/Guardian(s):
A great deal of information is presented in a short period of time during the Safe Sitter® course. We want every child to succeed in the course, 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. If your child needs accommodations, please let the Instructor or Site Coordinator know as soon as possible.
You can add any special considerations here
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Allergies
Does your child have any allergies such as foods or latex?
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Lunch Options
Select one
Jimmy John's
PB&J
I will bring my own lunch
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Emergency Medical Permission
Registered Provider
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Preferred Hospital
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Emergency Contact Phone (If Different)
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Alternate Emergency Contact
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Alternate Emergency Contact Phone Number
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I consent and agree the information in this section is true and accurate
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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.
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I give permission for my child to practice on the manikins.
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Other Terms and Conditions
- 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 of pictures or recordings taken of my child during the program for publicity purposes.
- Acknowledgement 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 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, the undersigned, have read this release and understand all of its terms. 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 and provide my signature as proof of acceptance.
- 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.
I Acknowledge
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CONSENT TO BE PHOTOGRAPHED, FILMED, VIDEOTAPED AND/OR INTERVIEWED AND RELEASE OF LIABILITY
I, the undersigned, hereby authorize Memorial Health System and its affiliates, in partnership with news and information media (when applicable), including but not limited to print, television, radio and internet/social media, to photograph or otherwise record and use, reproduce, publish, distribute, broadcast and exhibit my image, likeness and/or voice by still or moving pictures, digital photographs or recordings, videotape, audiotape and printed or other media (including, without limitation, the Internet) for advertising, news, promotion and/or educational purposes, such as presentations and publications.
I understand and agree that such photographs and other recordings may be scanned into computers and adjusted electronically and may be edited, cropped or otherwise modified at Memorial Health System’s discretion.
I understand that the information related to my medical care and treatment may be used or disclosed in the course of the purposes described above. I understand that the disclosure of such information is voluntary. I further understand that any disclosure of information comes with the potential for redisclosure and therefore the information may not be protected by federal privacy rules.
I hereby release and agree to indemnify and hold harmless Memorial Health System, its affiliates and their trustees, officers, employees, agents, patients and medical staff from any injury and/or damages sustained as a result of such photographing, filming, videotaping and/or interviewing, including, but not limited to, claims for personal injury, property damage, invasion of privacy and/or breach of confidentiality.
I agree to cause the photographing, filming, videotaping and/or interviewing to be stopped immediately upon the request of any physician or medical center employee, if in the sole judgment of said person, such is in the best interest of the care of any patient.
THIS IS A LEGAL CONSENT FORM AND RELEASE OF LIABILITY FORM. Please read it carefully and be sure your questions have been answered before consenting.
Photography Consent
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Parent / Guardian Signature (Please type your name to sign this form)
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