Relax Kids Registration and Consent Form Relax Kids Parents Registration and Consent Form Parent/Guardiand Name * Address * Phone * Mobile if different to above Number to ring in case of emergency * Password (if someone else is picking up your child) * Email * Child's name * Child's Age * Does your child have any known emotional or behavioural problems? * Yes No If you answered yes to above Please state in brief what and discuss this with your Relax Kids Coach. Does your child have epilepsy? Please let your coach know as breathing exercises can bring on a seizure. Yes No Does your child have asthma? Please make sure he/she brings his inhaler. * Yes No Does your child have severe allergies/anaphylaxis. If your child requires an epi-pen, please make sure you are in attendance. * Yes No Is your child taking any medication? * Yes No If you answered yes to above please state what medication: Is your child willing to take part in Relax Kids * Yes No How did you hear about Relax Kids? * Relax Kids classes include movement, stretches, visualisation, breathing exercises and children massag- ing each other (clothed). Do you consent to your child being involved? * Yes No Who is picking up the child? * Terms and Conditions: Please sign once you have read below. Who is picking up the child? I individually and as a parent and/or 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. Please note we charge £5.00 per 15 minutes if you are late picking up your child. I have read the Relax Kids child protection policy and in the event to my child not being collected I agree that Relax Kids can contact the social services duty officer for my child’s protection. I confirm that I have fully disclosed to Relax Kids and/or Coach any and all conditions (whether such conditions physical, mential, 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 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 they had taken reasonable care. Refund Classes: Prorated refunds will be given if cancellation is made in writing before the second attended class of the series. I understand and agree that I will not re-ceive any refund or credit for missed classes, but if cancellation of a class is due to failure on the part of Relax Kids I will be entitled to a reasonable refund of the charge for that class. After 2 classes it may be apparent to the Relax Kids Coach that classes are not appropriate for a child at this stage. In this instance we will request that the child is removed from the class and the balance will be refunded. * Signature Submit
