Kiwanis Club of Tysons
Registration Form
 
PLEASE COMPLETE SEPARATE FORM FOR EACH STUDENT REGISTERED

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
Manikin Practice
Safe Sitter® 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, VA to seek emergency care for my child.
The following person is authorized to make medical decisions for my child if I am unavailable
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, VA 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.
Which Class Will Student Attend *
Safe Sitter, Inc. does not provide CPR or other certifications, release the names of graduates, or act as a referral source of babysitters.