Happy Bees Baby Massage Booking Form

Happy Bees Baby Massage Booking Form
Your Name*

First NameLast Name
Address*

Street Address

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Name of course, month and time slot *
Do you have any learning or physical needs?*
Any cultural factors to be considered?
Do you have any chronic or acute health issues?*
What is your baby's name?*
What is your baby’s date of birth?*

DayMonthYear
Date
Are you or your baby on any medication?*
Does your baby suffer from any chronic health problems? (Including but not limited to hip/heart/digestive problems)*
Does your baby have any additional needs?*
Do you give permission for images and footage from the classes (in group or virtual) which may show you and your child/children to be used on any websites connected to Happy Bees Baby Massage along with social media such as Facebook and Instagram?*
Is there anything else you would like to make me aware of?*
I TAKE FULL RESPONSIBILITY FOR THE HEALTH OF MY CHILD AND MYSELF IN THE SESSIONS. SHOULD THERE BE ANY MEDICAL CHANGES I WILL CONSULT MY INSTRUCTOR. I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR MY CHILD THROUGHOUT THE COURSE
Signature

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DateTime
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