Grandparents Class Registration Form

Grandparents Class Registration Form
If you have questions about the class or have difficulty with the online form, please call Gloria Przygoda at 618-357-8878. Thank you!

This registration is for class on Tuesday, September 15th from 5-8pm.
Will one or two grandparents be attending?
- Name
  
  First NameLast Name
- Please list any allergies you have. If none, please put N/A.
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email (optional)
  We will send an email reminder prior to the class date.
- Emergency Contact Name
  
  First NameLast Name
- Emergency Contact Phone
  Please enter a valid phone number you can be reached at.Format: (000) 000-0000.
- Name
  
  First NameLast Name
- Please list any allergies you have. If none, please put N/A.
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email (optional)
  We will send an email reminder prior to the class date.
- Emergency Contact Name
  
  First NameLast Name
- Emergency Contact Phone
  Please enter a valid phone number you can be reached at.Format: (000) 000-0000.
- I understand the importance of attending the entire class and arriving on time to receive the full benefit of the training.
  The Registered Provider reserves the right to decline the application of any participant or dismiss any participant who, at the site's discretion, is disruptive or places themselves or others at risk.
  I consent to the use, reproduction, and publication by Safe Sitter®, Inc. and/or the Registered Provider of photographs or recordings taken during the program for educational or promotional purposes.
  Acknowledgement of Risk of Injury/Release and Waiver: I acknowledge and understand that there may be a risk of injury associated with participation in class activities. In consideration of my participation in the program, I agree to release, waive, hold harmless, and indemnify Safe Sitter®, Inc., the Registered Provider, and their respective employees, officers, members, and staff from liability for any and all claims arising from my participation in the program.
  I have read this release and understand all of its terms. I execute it voluntarily and with full knowledge of its meaning and significance.
  I certify that, to the best of my knowledge, I am physically able to safely participate in the activities included in this program.
  By submitting this registration form, I acknowledge that I have read and agree to the terms listed above and provide my signature as proof of acceptance.
  I consent to and authorize the Registered Provider to submit my name and address to Safe Sitter®, Inc. I understand that Safe Sitter®, Inc. will not sell, share, or trade this information with other organizations.
  
  By submitting this registration form, I acknowledge that I have read and agree to the terms listed above on behalf of myself and any additional attendee included on this registration. I certify that all information provided is accurate and provide my signature as proof of acceptance.
- Signature
- Should be Empty: