Chautauqua Safety Village · Babysitting Training Registration

Youth Name *

First Name

Last Name

If you are registering more than 1 youth, please list their first and last name(s) here

Youth Age(s) *

Parent Name *

First Name

Last Name

Contact Information

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Email *

Verify Email *

Parent Phone *

Class Fee *	Quantity
$75 - Monday, January 20, 2025: 9AM -1:30PM (School Holiday)

Please list any medical information or allergies if applicable

Photo Release *

I give permission for my child to have his/her picture or video taken a the Chautauqua Children's Safety Education Village and to have these photos or videos as a part of a press release, on our website, in any media including Facebook, Instagram and other social media sites, on television, in videos created to display our classes for advertising purposes. I confirm that I am the legal parent or guardian of the child on this application form.

Yes

No

Please Note

Your submission will not be finished until payment information has been completed. Once completed, you will receive an email confirmation. Please contact us with any questions. Thank you!