Register for a Babysitting Class

Student Name:		Parent/Guardian Name:
Address:

City:

State:

Zip:

Email:

Home Phone:		Work Phone:		Cell Phone:
Student Birthdate:		Age		Grade:

Dear Parent/Guardian:
The Babysitting Class is a fast-pace course with a great deal of new material presented quickly. If there is a problem with mastery of the material, we will ask your child to withdraw and alternate arrangements will be made for successful completion.

Does your child have any learning difficulties which might require special consideration to ensure a successful experience?	Yes No
To my knowledge, my child is emotionally mature and capable of babysitting.	Yes No

Emergency Medical Permission – Initials:

In the event of any life threatening problem, I authorize the Children’s Safety Village/SAFE KIDS to call 911 and have my child transported to any Emergency Department and authorize treatment by the doctor on call. • 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 unavailable , may be contacted and is authorized to act on behalf of my child.
Relationship Phone

Photographic Release – Initials
I consent and authorize the Children’s Safety Village/SAFE KIDS to use and reproduce photographs taken of my child during the Babysitting activities for the express purpose of publicity and public service presentations.

The Children’s Safety Village/SAFE KIDS assumes no responsibility for the acts or omissions of the student.
Fee: $65.00 (includes books & instructional materials). Please make check payable to: SAFE KIDS and mail to the address listed above. Suggested Attire: Some activities require sitting on the floor, so please dress accordingly Note: For the student to be registered, this form must be completed and returned with the fee payment prior to the class. Class will be cancelled if there are not 10 students registered.

Submit Cancel