Safe@Home Oregon January 15, 2026

Safe@Home Registration

Thursday, January 15, 2026 at Oregon School District Office, 123 E Grove Street
Student Name*

First NameLast Name
Name student wants to be called*
Name student wants to be called
Grade*

456
Student Date of Birth *

MonthDayYear
Parent/Guardian *

First NameLast Name
Parent/Guardian Phone (Cell) *
Parent/Guardian Phone (Cell)
Parent/Guardian Phone (Work) *
Parent/Guardian Phone (Work)
Address *

Address

Street Address Line 2

CityState

Zip
Parent/Guardian Email*
Parent/Guardian Email
Dear Parent/Guardian(s)
A great deal of information is presented in a short period of time during Safe Sitter® courses. 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?*

NoYes
If YES, please explain
Emergency Medical Permission
In the event of a health emergency, I authorize Stoughton Health to seek emergency care for my child. My preferred hospital is    Hospital* .
In the event of any accident or health problem which may require the attention of a physician, I may be contacted at      Phone Number*      .
If I am not available,     First Name*   Last Name*          may be contacted at        Phone Number*and is authorized to act on behalf of my child.
Other Terms and Conditions
- I will take all responsibility for deciding whether my child is capable and mature enough to stay home alone.
- I understand the importance of having my child attend and arrive on time.
- The Registered Provider reserves the right to decline the application of any student, or send home anystudent 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.
Signature of Parent/Guardian *

Clear
Date*

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

Copyright © 2016 by Safe Sitter, Inc.
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Safe@HomeRegistration fee is $25
$25.00

Total

$0.00
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Safe@Home Registration

Dear Parent/Guardian(s)

Allergies

Emergency Medical Permission