Relax Kids Registration Form

Childs Name

First Name C

Child's Date of Birth

Parent/Guardians Name

First Name Last Name

Phone Number

- Area Code Phone Number

Numbers to Ring Incase of Emergency & Relationship to the Child.

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Contact Name

First Name Last Name

Relationship To Child

Phone Number

- Area Code Phone Number

Password if someone else is picking up the child.

School Attended (or state Home Educated if applicable)

Does your child have any known emotional or behavioural problems? If Yes, Please state in brief what and discuss this with your Relax Kids Coach

Please give brief detail

Does your child have Epilepsy ? If Yes, please advise coach as breathing exercises may trigger a seizure

Does your child have severe allergies/anaphylaxis. If your child requires an epi-pen, please make sure you are in the building.

Does your child have Asthma ? If Yes, please advise coach & ensure they bring their inhaler

Is your child taking any medication, if Yes please give details

Please give detail

Please complete the following to the best of your knowledge and discuss any specific concerns you have with me and together we can support your child.

	Excellent	Good	Ok	Needs some extra support	Needs lots of extra support
Ability to be calm and peaceful at times.
Ability to deal with anxiety and stress.
Ability to express their feelings.
Self-esteem and self-confidence.
Ability to cope with feelings of Anger
Ability to openly show care and concern for themselves and others
Attention span.
Ability to listen
Sleep pattern.

How did you hear about Relax Kids

Relax Kids Classes include movement, stretches, visualisation, breathing exercises and children massaging each other (fully clothed). Do you consent to your child being involved.

I individually as a parent/guardian of the child identified above hereby agree to the following:

Parent’s Responsibilities: Relax Kids takes all reasonable care to ensure that its programmes are fun and safe. However, I understand that my child will be engaging in a moderate amount of physical activity that may involve some risk of injury. I acknowledge I have been advised to consult with my or my child’s physlcian with respect toany past or present injury, illness, health problem or any other condition or medication that may affect my child’s participation in the Relax Kids programme. In the event of emergency and in my absence agree to the Relax Kids Coach contacting Emergency Services. Please note we charge £5.00 per 15 minutes if you are late picking up your child.

My child’s protection.

I have read the Relax Kids Child Protection Policy and agree that in the event of my child not being collected I agree that Relax Kids can contact the duty social services duty officer for my childs protection.

I confirm that I have fully disclosedto Relax Kids and/or the Coach any and all conditions (whether physical, mental or behavioural or otherwise)that my child has or may have before my child participates in the class.

As far as is permitted under Local Law, I assume the above risks and accept responsibility for any injury sustained by my child. I further discharge and hold harmless Relax Kids including its owners, officers & personnel including its coaches and its suppliers) from any liability arising from any injury to my child or other persons or property caused by my child’s participation in the Relax Kids programme if that injury is caused either by my or my child’s fault; or by a third party unconnected with Relax Kids. The provision of services;or by events with Relax Kids, its owners, officers & personnel including its coaches and supplier, could not have foreseen or prevented even if they had taken reasonable care.

Refund Classes: Prorated refunds will be given if cancellation is made in writing before the second attended class of the series. I understand and agree that I will not re- ceive any refund or credit for missed classes, but if cancellation of a class is due to failure on the part of Relax Kids I will be entitled to a reasonable refund of the charge for that class. After 2 classes it may be apparent to the Relax Kids Coach that classes are not appropriate for a child at this stage. In this instance we will request that the child is removed from the class and the balance will be refunded.

Signature

DateTime

Relax Kids Registration & Consent Form