Safe Sitter

Safe at Home Registration Form

Grundy County Health Department
Friday, May 29 | 2:00 - 3:30 pm

Grundy County Health Department

Education Annex

1307 E. 17th 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
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Parent E-mail
example@example.com
Snacks are provided, does your student have any food allergies we should be aware of?
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.
Signature
Should be Empty:

Safe at Home Registration Form

Friday, May 29 | 2:00 - 3:30 pm

Parent Information