Safe Sitter Registration | Carlinville Area Hospital

Student Name:

Course Date(s):

Name student wants to be called:

Gender:

Grade:

Date of Birth:

Parent/Guardian:

Phone (Cell):

Phone (Work):

Phone (Secondary):

Address:

City:

State:

Zip:

Parent/Guardian Email:

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.

Allergies

Does your child have any allergies such as foods or latex?

YES

If YES, please explain:

Emergency Medical Permission

In the event of a health emergency, I authorize (Registered Provider)

to seek emergency care for my child.

My preferred hospital is

In the event of any accident or health problem which may require the attention of a

physician, I may be contacted at (Phone)

If I am not available, the registered provider listed above

may be contacted at (Phone)

and is authorized to act on behalf of my child.

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 he/she has a contagious illness including rash.

YES

I give permission for my child to practice on the manikins.

YES

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.
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 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.

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