Safe Sitter Registration Form

Safe Sitter Registration Form
If you have questions about the class or have difficulty with the online form, please call Gloria Przygoda at 618-357-8878. Thank you!
Class Date
- Student Name
  
  First NameLast Name
- Gender:
- Grade in School
  ex. 6th, 7th, 8th
- Student's Date of Birth
  
  MonthDayYear
  Date
- Please list any allergies student has. If none, please put N/A.
- Parent/ Guardian Name
  
  First NameLast Name
- Parent/ Guardian Phone
  Please enter a valid phone number you can be reached at.Format: (000) 000-0000.
- Alternate Phone
  Please list a secondary phone number we can contact for emergencies. Format: (000) 000-0000.
- Parent/ Guardian Email
  We will send a reminder email out before class.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- In the event of an emergency, I authorize the Registered Safe Sitter Providers (Instructors) to seek emergency care for my child. My preferred hospital is Preferred Hospital* . In the event of any accident or health problem which may require the attention of a physician, I may be contacted at (phone) Area Code* Phone Number* . If I am not available First Name* Last Name* may be contacted at Area Code* Phone Number* and is authorized to act on behalf of my child.
- Safe Sitter Includes practice of rescue skills on CPR manikins. Manikins require strict standards for controlling infection. I agree to not sent my child if he/she has a contagious illness including rash.
- I give permission for my child to practice on manikins
- I hereby consent to and authorize the following uses and reproductions by Pinckneyville Community Hospital (PCH), including the Family Medical Center, Area Health Education Center (AHEC), or anyone authorized by Pinckneyville Community Hospital, for any purpose, including but not limited to news releases, marketing, advertising, videos, fundraising, the hospital website, social media sites, and media interviews. I (student, job shadower, or volunteer) consent to Pinckneyville Community Hospital's use of photographs of me, with or without my name, for such purposes, including but not limited to publicity, illustration, advertising, web content, bulletin board, newsletter, and recognition programs. I understand I will not be compensated for this use. All negatives, together with the prints, videos and testimonials shall constitute the property of PCH, solely and completely. I understand that I may revoke this authorization in writing at any time by contacting the Marketing Director or Administrator/CEO of PCH at 5383 State Route 154 Pinckneyville, IL 62274, except to the extent that action has been taken in reliance on this authorization. Anyone under 18 years of age, authorization must be given by parent or guardian by signing below.
- We often publish a photo of the class on the hospital social media page and the newspaper. Please note if you consent to the marketing release above:
- - 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.
  - 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.
  - 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 online 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.
- Parent/ Guardian Signature
- My Products
  prevnext( X )
  
  Online Payment
  Breakfast and lunch are provided.
  
  $15.00
  
  Pay in Person
  I prefer to pay $15 in person via cash or check the morning of the class.
  
  Free Quantity
  
  Total
  
  $0.00
- Payment Methods
  
  Fastlane Checkout
  
  Choose from one of the PayPal options to make your payment.
  
  Contact Info
  
  Payment Info
- Should be Empty:

Safe Sitter Registration Form

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