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
DateTime
Should be Empty: