SafeSitter Registration Form SafeSitter Registration Form "*" indicates required fields Class Date Desired* MM slash DD slash YYYY (fill in desired date)Student Name* First Last Birth Date* MM slash DD slash YYYY Sex* Male Female Grade* Name student wants to be called Parent/Guardian* Phone - Home*Phone - Work*Phone - Cell*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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.Allergies* Yes No Allergies - Please Explain Manikin Practice 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.Illness* I agree not to send my child if he/she has a contagious illness including rash.*Manikin Permission* I give permission for my child to practice on the manikins.*Emergency Medical Permission In the event of a health emergency, I authorize Tomah Memorial Hospital 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 am not available,* May be contacted at (phone)* and is authorized to act on behalf of my child.Terms & Conditions* I agree.Other Terms and Conditions Tomah Memorial Hospital 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 Tomah Memorial Hospital 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 Tomah Memorial Hospital 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 Tomah Memorial Hospital to submit the name and address of my child to SafeSitter, Inc. I understand that Safe Sitter, Inc. will not sell, share or trade this information with other organizations. Signature* Date* MM slash DD slash YYYY Safe Sitter, Inc. does not provide CPR or other certifications, release the names of graduates, or act as a referral source of babysitters.