• Safe at Home Registration Form

    Grundy County Health Department

  • Thursday, July 30 | 2:30 - 4:00 pm

    Grundy County Health Department

    Education Annex

    1307 E. 17th Street | Trenton, MO 64683

    safesitter@grundycountyhealth.org

    $5 class fee

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Snacks are provided, does your student have any food allergies we should be aware of?*

  • 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.*

  • Photo Release

    I give permission for photos of my child taken during the Safe Sitter class to be used for promotional materials, publications, and social media posts about the class.

  • Photo Permission*
  • Should be Empty: