MooBorn Massage Course Booking Form

MooBorn Massage Course Booking Form

Moo Music Coalville & Ashby de la Zouch
Contact Details
Full Name *

First Name Last Name
Mobile Number *
Email Address *
example@example.com
Baby's Information
Full Name *

First Name Last Name
Date of Birth *

/ Day / Month Year
Date
Was your baby born before 38 weeks gestation? *

Yes No
Corrected Age
Baby’s chronological age minus the number of weeks or months s/he was born early
Medical Details
Doctor's Name *

Doctor's Address *

Please answer the below questions, if needed please enter comments in the box below *

	Yes	No
Has your child had their 6 week check up?
Does your child seem to settle well?
Does your child have any skin infections or broken skin?
Does your child have any known allergies?
Does your child have any problems with their hips, heart or tummy?
Has your child had any recent surgery within the last 2 months?
Does your child have any convulsions or neurological problems?
Does your child suffer any wind, colic or digestive problems?
Does your child suffer from any respiratory problems (eg. asthma)?
Is your child currently on any medication?
Are there any reasons why medical approval may be required?

Comments
Course to book *

David Taylor Hall, Heather - Thursdays @ 12pm David Taylor Hall, Heather - Dad's Massage
Course Dates *
1. 28th February 2019
2. 7th March 2019
3. 14th March 2019
4. 21st March 2019
5. 28th March 2019
6. 4th April 2019
1. 2nd May 2019
2. 9th May 2019
3. 16th May 2019
4. 23rd May 2019
5. 6th June 2019
6. 13th June 2019
1. 6th April 2019
2. 13th April 2019
Massage Consent *

I DO CONSENT to receiving baby massage instructions I DO NOT CONSENT to receiving baby massage instructions
Photography Consent *

I DO CONSENT to photographs being taken during the class which may be used by Moo Music Coalville and Ashby de la Zouch for any publicity material they wish to present it on I DO NOT CONSENT to photographs being taken during the class which may be used by Moo Music Coalville and Ashby de la Zouch for any publicity material they wish to present it on
Promo Code
Cost
Payment Type *
Would you like to be kept informed about special offers and noo Moo sessions? *

Yes No
Parent/Guardian Declaration
- I declare that all information I have given about my child is all true and correct as far as I am aware
- I take full responsibility for the wellbeing and welfare of my child during the class sessions and will only carry out the massage as shown and instructed by the teacher
- I will endeavour to inform the teacher before the class starts should my child have a contra-indication to the massage so that not to disturb the rest of the members of the class
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