Stepping Stones with SamRegistration & Consent Form

Child's Name

First Name Surname

Child's Date of Birth

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Parent/Guardian's Name

First Name Surname

Phone Number

Area Code Phone Number

Mobile

Email

example@example.com

Emergency contact for the child.

Contact Name

First Name Last Name

Relationship To Child

Phone Number

Area Code Phone Number

Mobile

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 Sam

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 Stepping Stones with Sam

Group Stepping Stones with Sam 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: Stepping Stones with Sam takes all reasonable care to ensure that its programmes are fun and safe. However, I understand that my child may 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 doctor with respect to any past or present injury, illness, health problem or any other condition or medication that may affect my child’s participation in the programme. In the event of emergency and in my absence agree to the Stepping Stones with Sam contacting Emergency Services. Please note we charge £5.00 per 15 minutes if you are late picking up your child.

I confirm that I have fully disclosed to Stepping Stone with Sam 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.

My child’s protection.

I am aware that Stepping Stones with Sam has undergone Safeguarding training and will work within the required guidelines and legislation.

Refund Classes: Proratad 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 receive any refund or credit for missed classes, but if cancellation of a class is due to failure on the part of Stepping Stones with Sam I will be entitled to a reasonable refund of the charge for that class. After 2 classes it may be apparent to the 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

Date