American Red Cross

      Babysitter’s Training

 

Where: Deerfield Public Library

When: Thursday, March 27, 2008

Times: 9:00-4:00pm

Ages: 11 to 15

Cost: $55.00 per person

Registration Deadline: Friday, March 21, 2008

*** Registration is limited to 12 students. (First Come First Serve)     

 

Participant Name _________________________________________________________________

Date of Birth                                                   Age                                                Grade _____________

Mailing Address                                                                   City                                        Zip ________

Parent/Guardian(s) Name ___________________________________________________________

Home Phone                                                                  Work Phone __________________________

Medical Concerns/Allergies _________________________________________________________

Emergency Contact ________________________________       Phone _______________________

                                      (in case the parent/guardian cannot be reached)

 

IMPORTANT

Waiver of Participation

Please read and sign the following

I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the Deerfield Community Center (the "DCC"), its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with youth programs (the "Programs") and in consideration for the DCC accepting the registrant for its Programs and activities, I hereby release, discharge and/or otherwise indemnify the DCC, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the programs and/or being transported to or from the same, which transportation I hereby authorize.  As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.

 

                                                                                                                                                                                                                               

Printed Name of Parent/Legal Guardian                                        Signature                                                              Date                                       

 

Text Box: IMPORTANT
Waiver of Participation
Please read and sign the following
I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the Deerfield Community Center (the "DCC"), its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with youth programs (the "Programs") and in consideration for the DCC accepting the registrant for its Programs and activities, I hereby release, discharge and/or otherwise indemnify the DCC, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the programs and/or being transported to or from the same, which transportation I hereby authorize.  As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.
 
                                                                                                                                                                                                                                
Printed Name of Parent/Legal Guardian                                        Signature                                                              Date                                        
 

 

Return form to the Deerfield Community Center, 3 W Deerfield St., Deerfield, WI 53531

For more information please contact Julie Schwenn at 764-5935.