Safe Sitter Registration Form

The Macon County Health Department is hosting a Safe Sitter class on Saturday, May 16, 2026 from 8:30am - 2:30pm. Class will take place at the Macon County Health Department. Your child should bring a sack lunch with them to the class. The class will be hands on and recommended for students in grades 6-8.

Student Name*

Preferred Name

Grade*

Date of Birth*

Date

Sex*

FemaleMale

Parent/Guardian*

Phone (Cell)*

Format: (000) 000-0000.

Phone (Secondary)

Format: (000) 000-0000.

Phone (Secondary)

Format: (000) 000-0000.

Address*

Address

Street Address Line 2

CityState

Zip

Parent/Guardian Email

example@example.com

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.

Does your child have any allergies, such as food or latex?*

NoYes

If YES, please explain

If I'm not available, a secondary contact may be contacted and is authorized to act on behalf of my child in the event of an emergency: (name)*

Secondary contact

They may be contacted at (phone)*

Format: (000) 000-0000.

Safe Sitter includes practice of rescue skills on CPR manikins. Manikins require strict standards for controlling infection. I give my child permission to practice on the manikins*

YesNo

I will take all responsibility for deciding whether my child is capable and mature enough to babysit.
I agree not to send my child if he/she has a contagious illness including rash.
I understand the importance of having my child attend the 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.
In the event of a health emergency, I authorize Macon County Health Department to seek emergency care for my child at Samaritan Hospital in Macon, MO.
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 understand the cost of the course is $45 and I will come to the Macon County Health Department to make the payment by Thursday, May 14, 2026.*

I understand

If a student cancels greater than 24 hours in advance, they will receive a full refund. If it is less than 24 hours, they will receive a 50 % refund. If the student is a no call or show on the day of the class, they will not receive a refund.*

I understand

Type a question

Date

Safe Sitter, Inc. does not provide CPR or other certifications, release the names of graduates, or act as a referral source of babysitters.