Relax Kids Registration Form

Childs Name

First Name Last Name

Child's Date of Birth

Month Day Year

Parent/Guardians Name

First Name Last Name

Phone Number

Area Code Phone Number

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

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

Contact Name

First Name Last Name

Relationship To Child

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

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 to any 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.

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.

Signature

DateTime