Home Alone Registration
Tuesday, June 16, 2026 8 am -12 pm SGCMH Education Conference Room
Participant's Name
*
First Name
Last Name
Parent/Guardian Name
*
First Name
Last Name
Email Address
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the participant a child/grandchild of a SGCMH Employee? (Class is free for children/grandchildren of SGCMH employees.)
*
Yes
No
Photo Release: I hearby authorize Ste. Genevieve County Memorial Hospital to release my son/daughter's name and or photograph for a news release to the local media and to use my son/daughter's photo on the hospital's website or Facebook page.
*
Yes
No
Signature
*
My Child has permission to go home with:
First Name
Last Name
Submit
Submit
Should be Empty: