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To use this page:
1.
Go to the file menu and
select “edit with Microsoft Word”.
2.
Fill out form.
3.
Save form as registration.doc
4.
Attach document to email
addressed to acosmicbutterfly@yahoo.com
Infant Massage - Registration Form
1. Parents/Caregivers Name(s): Single/Married
2. What your children’s names, ages, and
dates of birth?
3. Do you have adopted or foster children? If so, who(m)?
4. Do any of your children have any medical
conditions or special needs of any kind?
*If you answered yes to question 4,
indicate names of child(ren),
and briefly explain medical condition and/or special needs.
*If
you are the parent(s) of a child with a medical condition and/or special
needs, written permission from your child’s attending pediatrician is
required to determine if massage is appropriate. In some cases, a release
of information may also be required to establish communication between
your infant massage instructor and your child’s pediatrician with regard
to your child’s medical condition and/or special needs.
5. Please choose from one of the following
options to meet with your infant massage instructor. If you elect more
than one time slot, please put them in order from most to least desired.
Monday 10am – 11:30am Thursday 10am – 11:30am
Tuesday 10am – 11:30am Friday 10am – 11:30am
Wednesday 6pm – 7:30pm Saturday 3pm – 4:30pm
*Would you
prefer private sessions in your home or group sessions outside your home?
6. Please provide the following information.
Address:
Phone:
Email:
7. Is your family interested in receiving
therapeutic massage service for your whole family?
Other comments:
Thank you for registering for infant massage
classes. You will be contacted in 2-3 business days to establish a schedule
and address any questions or concerns you may have. Please feel free to
email me any time before, during, or after your infant massage training
with questions or concerns regarding infant massage. I look forward to
working with you and your family!
I/We, the undersigned do hereby acknowledge and
agree to the stated terms and conditions of this registration agreement.
Parent(s)/Caregivers Signature Date
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