Safe Sitter

Please select your course date:*

Join Interest List

Student's Name*

First NameLast Name

Student's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student's Birthdate*

Date

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Email*

example@example.com

Parent/Guardian Phone #*

Please enter a valid phone number.

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 require any type of accommodations?

Leave blank if n/a

Does your child have any allergies to food or latex?

List, or leave blank if n/a

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 they have a contagious illness, including a cough, fever, or rash.

I give permission for my child to practice on manikins.

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.
• Harris County Emergency Services District 8 reserves the right to decline the application of any student or send home any student who, in their discretion, is disruptive or puts him/herself or others at risk.
• I consent to the use, reproduction, and publication by Safe Sitter, Inc. and/or Harris County Emergency Services District 8 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 Harris County Emergency Services District 8 and
their respective employees, members, officers, and other staff members from liability to us and our child for any and all claims.

• I have read this release and understand all of its terms. I execute it voluntarily and with full knowledge of its meaning and significance.

• I 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 Harris County Emergency Services District 8 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.

Parent/Guardian Signature

Safe Sitter Course Enrollment Form