Safe Sitter Registration

This form is used to register for the Safe Sitter program offered by the Kiwanis Club of Tysons Corner/McLean, VA.

Class Date *

Select the date of class you wish to register for.
Alternate Class Date *

Select the date of class you would like to register if your primary choice is already full.
Student Name * First Last
Enter the first and last name of the student.
Date of Birth * / MM / DD YYYY
Enter the student's date of birth. Students can only be 11-13 years old. Unfortunately, no exceptions are permitted.
Gender *

Select the gender of the student.
Grade in School

Enter the school grade of the student.
Name student wants to be called in class

Enter the name the student by which the student wishes to be called by in class (if different than first name).
Parent/Guardian Name * First Last
Enter the first and last name of the parent/guardian of the student.
Parent/Guardian Email *

Enter the email address for the parent/guardian
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Enter the full address for the student.
Home Phone * - (###) - ### ####
Enter the home phone number for the parent/guardian.
Cell Phone - (###) - ### ####
Enter the cell phone number for the parent/guardian.
How did you hear about Tysons Corner Kiwanis' Safe Sitter Program?

Enter information about how you found out about this class.
Dear Parent/Guardian(s):
A great deal of information is presented in a short period of time during the Safe Sitter® class. We want every child to succeed in
the class, 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 in class.
I will take all responsibility for deciding whether my child is capable and mature enough to babysit.
*

Please answer "Yes" or "No"
I understand the importance of having my child attend each class session and arrive on time.
*

Please answer "Yes" or "No"
Does your child have any allergies such as foods or latex?
*

Please answer "Yes" or "No"
Manikin Practice
Safe Sitter® class includes practice of rescue skills on CPR manikins. Manikins require strict standards for controlling infection.
I agree not to send my child to class if he/she has a contagious illness including rash. *

Please answer "Yes" or "No"
I give permission for my son/daughter to practice on the manikins. *

Please answer "Yes" or "No"
Emergency Medical Permission
In the event of a health emergency, I authorize the Kiwanis Club of Tysons Corner/McLean, VA (site) to seek emergency care for my child.
My preferred hospital is *

Enter preferred hospital to send student to in a medical emergency.
In the event of any accident or health problem which may require the
attention of a physician, I may be contacted at * - (###) - ### ####
Enter phone number to call in a medical emergency.
Name of responsible adult if parent/guardian is not available *

Enter the name of an adult to contact if parent/guardian is unreachable in a medical emergency.
Phone number of responsible adult if parent/guardian is not available * - (###) - ### ####
Enter phone number of adult to call if parent/guardian is unreachable.
Other Terms and Conditions
• The teaching site 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 teaching site 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 teaching site 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 Kiwanis Club of Tysons Corner, VA
(site) 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.
Type full name of Parent/Guardian indicating acceptance of Terms & Conditions *

Enter full name of parent/guardian.

Safe Sitter Registration

Safe Sitter Registration

Manikin Practice Safe Sitter® class includes practice of rescue skills on CPR manikins. Manikins require strict standards for controlling infection.

Emergency Medical Permission In the event of a health emergency, I authorize the Kiwanis Club of Tysons Corner/McLean, VA (site) to seek emergency care for my child.

Manikin Practice
Safe Sitter® class includes practice of rescue skills on CPR manikins. Manikins require strict standards for controlling infection.

Emergency Medical Permission
In the event of a health emergency, I authorize the Kiwanis Club of Tysons Corner/McLean, VA (site) to seek emergency care for my child.