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27
Questions
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1
Your Name
First Name
Last Name
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2
Child's Name (Child 1)
First Name
Last Name
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3
Child's Age
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4
Which Session will this child attend?
Mindful Kids YMCA (5-9 yrs)
Mindful Kids Chill Skills YMCA (9-12 yrs)
One to One session
Calm & Create Workshop
Zendoodle Workshop
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5
Child's Name (Child 2 if applicable)
First Name
Last Name
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6
Child's Age
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7
Which Session will this child attend?
Mindful Kids YMCA (5-9 yrs)
Mindful Kids Chill Skills YMCA (9-12 yrs)
One to One session
Calm & Create Workshop
Zendoodle Workshop
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8
Have you already filled in a consent form for your child/ren
If your child has previously attended Relax With Suzy sessions and you have filled in a consent form then choose 'No' and you will skip to the end of the consent form.
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NO
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9
Your Email
example@example.com
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10
Address
Start typing your street address or postcode and select from list
Street Address
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City
State / Province
Postal / Zip Code
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Western Sahara
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Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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11
Mobile Number
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12
Emergency Contact
First Name
Relationship to Child
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13
Phone Number
Area Code
Phone Number
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14
(if someone else picks up child)
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15
Does your child have any known emotional or behavioural problems?
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NO
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16
Please state details here
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17
Does your child have epilepsy?
Please let your coach know as breathing exercises can bring on a seizure.
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NO
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18
Does your child have asthma? Please make sure he/she brings his inhaler.
Please make sure he/she brings his inhaler.
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NO
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19
Does your child have severe allergies/anaphylaxis? If your child requires an epi-pen, please ensure this is brought with them.
If your child requires an epi-pen, please ensure this is brought with them.
YES
NO
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20
Is your child taking any medication?
If Yes, Please discuss any concerns with your RK coach
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NO
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21
Is your child willing to do Relax Kids?
YES
NO
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22
How did you find out about Relax Kids?
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23
Relax Kids classes include movement, stretches,visualisation, breathing exercises and self-massage/children massaging each other (clothed). Are there any aspects to this you do not give consent to?
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24
Who will usually be picking up the child?
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25
I hereby give permission for Relax With Suzy to use the above named children’s photos for promotional purposes on the Relax With Suzy Facebook page and/or www.relaxwithsuzy.co.uk
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NO
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26
Do you give permission for your child to be given raisins, chocolate or plain biscuits (i.e. Rich Tea) as part of the sessions? (i.e. for mindful eating)
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NO
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27
I agree to the Terms & Conditions:
Liability Disclaimer and Notice Parent’s Responsibilities: Relax With Suzy 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 physician 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 With Suzy programme. In the event of emergency and in my absence agree to the Suzy contacting Emergency Services. Please note we charge £5.00 per 15 minutes if you are late picking up your child. I confirm that I have fully disclosed to Relax With Suzy any and all conditions (whether such conditions are physical, mental, 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 With Suzy from any liability; arising from any injury to my child or other persons or property caused by my child's participation in the Relax With Suzy programme if that injury is caused either by my or my child's fault: or by a third party unconnected with Relax With Suzy provision of services; or by events with Relax With Suzy its owner, officers and personnel including its coaches and its suppliers could not have foreseen or prevented even if 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 receive any refund or credit for missed classes, but if cancellation of a class is due to failure on the part of Relax With Suzy I will be entitled to a reasonable refund of the charge for that class. After 2 classes it may be apparent to the Relax With Suzy 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.
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NO
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28
Parent/Guardian Signature
Clear
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29
Tags
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In Progress
Done
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