Circle of Parenting

For parents/caregivers with babies 0-12 months
and expecting parents/caregivers

Mondays, Sep 12- Dec 12 2022
No Class Indigenous People's Day (Oct 10) and Thanksgiving Week (Nov 21)
12-week session

11:30am-12:45pm

This class is expected to fill to capacity

Offered at sliding scale/scholarship, see payment options below.

Location: Held outdoors in the flat, gated area behind the Secure Beginnings Center

555 Mahoney Ave Ojai CA 93022.

Enter the large main gate to the Oak View Park and Resource Center, walk back toward the library. We meet in the gated area to the left, behind the state preschool.

So that we can aggregate data for use in grant applications to receive funding for our programs and scholarships, we are asking for the following demographical information.

Fields marked with a * are required fields.

Primary Caregiver

Primary Caregiver's Name

*

First Name

Last Name

Primary Caregiver’s Relationship to Child

*

Email

*

Verify Email

*

Phone

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Primary Caregiver's Birth Date

(mm/dd/yyyy)

Primary Caregiver’s Gender

Primary Caregiver's Ethnicity

Primary Caregiver’s Sexual Orientation

Primary Caregiver's Disability Status

Partner/Secondary Caregiver

Partner/Secondary Caregiver's Name

First Name

Last Name

Partner/Secondary Caregiver’s Relationship to Child

Partner/Secondary Caregiver's Birth Date

(mm/dd/yyyy)

Partner/Secondary Caregiver’s Gender

Partner/Secondary Caregiver’s Ethnicity

Partner/Secondary Caregiver’s Sexual Orientation

Partner/Secondary Caregiver’s Disability Status

Child Information

Child's Name

*

First Name

Last Name

Child's Date of Birth

*

(mm/dd/yyyy)

Child's Gender

Child's Ethnicity

Child's Disability Status

Household Information

Household Income

*

Number of People in Household

*

What is the primary language spoken at home?

*

Is there anything else you'd like to share with us about your family?

Photo Release

I grant Secure Beginnings, its representatives and employees the right to take photographs and video of me and my child. I authorize Secure Beginnings, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I am registering for

Please only complete one registration form per family. If you would like to attend multiple drop-in classes, you can email programs@securebeginnings.org with the dates you'd like to attend.

Full Session (Sep 12 - Dec 12)

Single Drop-In Class

Please indicate which drop in class you are registering for

*

Payment

Circle of Parenting Class Payment

*

$264 - Full Session

$294 - Session + add $30 to my payment to help fund scholarships for other families

$220 - 25% scholarship

$132 - 50% scholarship

$66 - 75% scholarship

$0 - I am in need of a full scholarship

$22 - I am paying for a single drop-in class

$

Policy and Waiver

In consideration of my participation in this activity, I acknowledge and agree to the following:

SELF SCREENING: Please refrain from coming to class if (1) anyone in your household has COVID or other contagious illness, or has had close contact with someone who has COVID or other contagious illness -or- (2) in the last 24 hours you or your child has experienced any of the following: fever, congestion / runny nose, headache, cough, sore throat, difficulty breathing, fatigue and muscle or body aches, loss of taste or smell, or nausea, vomiting, or diarrhea.

If you test positive for COVID, and have no symptoms, we invite you to attend class after day 5. Please do not attend programs until you are symptom-free including fever-free without the use of fever-reducing medications) for 24 hours.

I am fully and personally responsible for my own safety and actions while and during my participation and I recognize that I may be at risk of contracting COVID-19.

With full knowledge of the risks involved, I hereby release, waive, discharge Secure Beginnings, its' board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.

I agree to indemnify, defend, and hold harmless Secure Beginnings from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

I understand that this policy may be updated during the course of the class series, in adherence with public health guidelines.

Electronic Signature: I acknowledge that I have read and understood the entire contents of this Policy and Waiver.

*

First Name

Last Name

Date Signed

*

(mm/dd/yyyy)

Circle of Parenting

For parents/caregivers with babies 0-12 monthsand expecting parents/caregivers

Mondays, Sep 12- Dec 12 2022 No Class Indigenous People's Day (Oct 10) and Thanksgiving Week (Nov 21)12-week session

11:30am-12:45pm

*This class is expected to fill to capacity*

Offered at sliding scale/scholarship, see payment options below.Location: Held outdoors in the flat, gated area behind the Secure Beginnings Center

Primary Caregiver

Partner/Secondary Caregiver

Child Information

Household Information

Payment

For parents/caregivers with babies 0-12 months
and expecting parents/caregivers

Mondays, Sep 12- Dec 12 2022
No Class Indigenous People's Day (Oct 10) and Thanksgiving Week (Nov 21)
12-week session

This class is expected to fill to capacity

Offered at sliding scale/scholarship, see payment options below.

Location: Held outdoors in the flat, gated area behind the Secure Beginnings Center