Circle of Parenting

For expecting parents and caregivers with babies under 6 months of age*

*In order to maintain social distancing, we cannot accommodate older siblings

Adapted for COVID-19 transmission prevention

4 Tuesdays, Oct 27 - Nov 17 from 9:30-10:30am

LOCATION: FOSTER PARK

37 Casitas Vista Rd. Ventura, CA 93001

Suggested donation $10 per gathering

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 2020 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.

Please indicate which date(s) you are registering for

*

October 27

November 3

November 10

November 17

Payment

Circle of Parenting Donation-Based Payment

*

$0 - Free Class(es), No Donation

$10 - Free Class(es) and add $10 to help a family in need attend classes

$20 - Free Class(es) and add $20 to help a family in need attend classes

$30 - Free Class(es) and add $30 to help a family in need attend classes

$40 - Free Class(es) and add $40 to help a family in need attend classes

$

COVID-19 Liability Release 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 through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions which Secure Beginnings adheres to comply.

In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following:

*

I am aware of the existence of the risk on my physical appearance to the venue and my participation to the activity of Secure Beginnings that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.

*

I have not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.

*

I have not, nor any member(s) of my household, traveled by sea or by air, internationally within the past 30 days.

*

I did not, nor any member of my household, visit any any area within the United States that was reported to be highly affected by COVID-19, in the last 30 days .

*

I have not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days.

Following the pronouncements above I hereby declare the following:

*

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.

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

Electronic Signature

*

First Name

Last Name

Date Signed

*

(mm/dd/yyyy)

Circle of Parenting

For expecting parents and caregivers with babies under 6 months of age*

*In order to maintain social distancing, we cannot accommodate older siblings

Adapted for COVID-19 transmission prevention

4 Tuesdays, Oct 27 - Nov 17 from 9:30-10:30am LOCATION: FOSTER PARK

37 Casitas Vista Rd. Ventura, CA 93001

Suggested donation $10 per gathering

Primary Caregiver

Partner/Secondary Caregiver

Child Information

Household Information

Payment

4 Tuesdays, Oct 27 - Nov 17 from 9:30-10:30am

LOCATION: FOSTER PARK