Circle of Parenting

For parents/caregivers with babies 0-8 months
and expecting parents/caregivers

10 Tuesdays, September 7 - November 9, 2021 11:30am-12:45pm

Location:

Held outdoors in the back yard of the Secure Beginnings Center in at 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 on the lawn to the left, behind our classroom.

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.

Have you completed a full registration form for any of our 2021 classes?

*

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

Country

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.

Payment

Circle of Parenting Donation-Based Payment

*

$0 - Free class(es), no donation

$10 - Donation-based class payment

$22 - Donation-based class payment, suggested donation per class

$220 - Donation-based class payment, suggested donation for this session (10 classes)

$

COVID-19 Mitigation and Waiver

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person, the government has set recommendations, guidelines, and some prohibitions which Secure Beginnings adheres to comply.

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

*

I will refrain from coming to class if (1) in the last 14 days anyone in my household has had close contact with someone who has or is suspected of having COVID -or- (2) in the last 48 hours my child or I have 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. I will not attend programs until having a negative COVID test, an alternative diagnosis from a doctor, or 10 days symptom free.

*

I am fully and personally responsible for my own safety and actions while and during may participation and I recognize that I may be in any case 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.

Electronic Signature

*

First Name

Last Name

Date Signed

*

(mm/dd/yyyy)

Circle of Parenting

For parents/caregivers with babies 0-8 monthsand expecting parents/caregivers

10 Tuesdays, September 7 - November 9, 2021 11:30am-12:45pmLocation:

Primary Caregiver

Partner/Secondary Caregiver

Child Information

Household Information

Payment

For parents/caregivers with babies 0-8 months
and expecting parents/caregivers

10 Tuesdays, September 7 - November 9, 2021 11:30am-12:45pm

Location: