Fillable Child and Babysitting Safety - Registration (Lake Havasu City)

Fill Online, Printable, Fillable, Blank Child and Babysitting Safety - Registration (Lake Havasu City) Form

Use Fill to complete blank online LAKE HAVASU CITY (AZ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Child and Babysitting Safety - Registration (Lake Havasu City)

On average this form takes 9 minutes to complete

The Child and Babysitting Safety - Registration (Lake Havasu City) form is 2 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 31 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Lake Havasu City

BROWSE LAKE HAVASU CITY (AZ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
LAKE HAVASU CITY FIRE DEPARTMENT
FIRE PREVENTION BUREAU
2330 McCulloch Blvd. N.
Lake Havasu City, AZ 86403
(928) 855-1141 lhcfire@lhcaz.gov
FD-288 Updated/CA 10-01-2019 P a g e | 1
Child and Babysitting Safety - Registration
PARTICIPANT INFORMATION- PLEASE COMPLETE IN FULL
Last Name, First Name
M/F
Date of Birth
Age (11-15)
Grade
Dates requested:
1
st
Choice:
2
nd
Choice:
3
rd
Choice:
Notes:
Parent/Guardian Name:
Cell Phone:
Work Phone:
Parent/Guardian Name:
Cell Phone:
Work Phone:
Email Address:
Home Phone:
Emergency contact:
Phone:
Relationship:
Phone:
Relationship:
Photographs may be taken for promotional purposes during the program. May the Participant’s photo be published in brochures
and media releases?
Yes
No
Does the Participant have any medical conditions, behavioral issues, or allergies? If yes, fill out the Additional Health Information & Epi
Pen form. (FD-288A)
Yes
No
Please make checks payable to: Lake Havasu City
No refunds unless class/program is cancelled
FOR OFFICE USE ONLY
Total Due:
Date Paid:
Class Date:
Payment Type:
Cash
Check#
Credit Card
By:
Emergency Medical Release
LAKE HAVASU CITY FIRE DEPARTMENT
FIRE PREVENTION BUREAU
2330 McCulloch Blvd. N.
Lake Havasu City, AZ 86403
(928) 855-1141 lhcfire@lhcaz.gov
Child and Babysitting Safety - Registration
FD-288 Updated/CA 10-01-2019 P a g e | 2
To the best of my knowledge, Participant is in good health and adequately immunized to participate in this program. In the event
Participant is injured or should require medical attention, I authorize the securing of necessary medical treatment. I acknowledge that I
will be responsible for all costs associated with any medical treatment. Confirmation of this authorization will be attempted if the
circumstances permit prior treatment by calling the telephone numbers provided.
Hold Harmless Clause
To the fullest extent permitted by law, Participant and Participant’s parent or guardian agree to indemnify, defend, save, and hold harmless
Lake Havasu City, its departments, agencies, boards, commissions, officers, officials, agents, volunteers, and employees (“Indemnitee”)
for, from, and against any and all claims, actions, liabilities, damages, costs, losses, or expenses (including, but not limited to, court costs,
attorneys’ fees, and costs of claim processing, investigation and litigation) to which any Indemnitee may become subject, under any theory
of liability (“Claims”) to the extent that Claims are caused by the negligent acts, recklessness, or intentional misconduct of the Participant
arising out of or as a result of participation in this program. Participant/Parent/Guardian agrees to be responsible for primary loss
investigation, defense, and judgement costs where this indemnification is applicable.
Waiver
Participant and Participant’s parent or guardian waive the right to any claim for damages or injury of any kind on behalf of Participant,
accruing to Participant arising out of or as a result of participation in the program.
I declare that I am the Participant’s parent or guardian. I acknowledge that I read this form completely and understand the responsibilities
and privileges of participating in this program. Participation in this program is voluntary. Lake Havasu City is not responsible for lost or
stolen items. Lake Havasu City reserves the right to reconcile customer balances when participant has available account credit.
Signature:
Date:
Parent/Legal Guardian
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Child and Babysitting Safety - Registration (Lake Havasu City)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document