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2024 Babysitting Training Scholarship Request

The Safety Village can offer 3 scholarships per course date. These are issued on a first come, first serve basis. Please complete the form and a staff person will reach out to confirm class availability.

Youth Name *

First Name

Last Name

Youth Age *

Parent or Guardian Name *

First Name

Last Name

Number of People in Your Household *

Annual Household Income *

$0 - $19,999

$20,000 - $29,999

$30,000 - $39,999

$40,000 - $49,999

$50,000 or Greater

Contact Information

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Email *

Verify Email *

Parent Phone *

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