REBOUND- Consent and Medical Form

REBOUND- Consent and Medical Form
Rebound therapy offers a great benefit for our children -
- Cardio-respiratory/stamina
- Muscle tone – build and maintain, helps to relax the muscles through rhythmic movement minimising tremors.
- Posture- Works the core to help support upper and lower limbs.
- Balance- works on uneven surfaces improving walking and standing.
- Communication- encourages eye to eye contact, builds trust between adults and children, through exercise and cardio it helps with vocalisation.
- Peer interaction , building friendships
- Helps to flush the body of toxins – toileting, sweating etc
- Perception of the body in space/spatial awareness
- Time to respond to instructions and exercise
- Cross curricular:- Numeracy, colour recognition, Literacy
- Sense of achievement
- Self-Confidence, self-image, independence
- Freedom of movement
Above all, rebound is FUN!
Child's Name *

First Name Last Name
Does the participant have any of the following?
Spinal rodding? *

YES NO
Comments (initial)
Dwarfism? *

YES NO
Comments (initial)
Brittle bones? *

YES NO
Comments (initial)
Atlanto-axial instability (confirmed)? *

YES NO
Comments (initial)
Detaching retina(s)? *

YES NO
Comments (initial)
Detached retina(s)? *

YES NO
Comments (initial)
Osteoporosis? *

YES NO
Comments (initial)
Haemophilia? *

YES NO
Comments (initial)
Cardiac or circulatory problems? *

YES NO
Comments (initial)
Epilepsy? *

YES NO
Comments (initial)
Arthritis or Stills Disease? *

YES NO
Comments (initial)
Asthma/ respiratory problems? *

YES NO
Comments (initial)
Cystic Fibrosis? *

YES NO
Comments (initial)
Muscular Dystrophy? *

YES NO
Comments (initial)
Spina Bifida or Hydrocephalus? *

YES NO
Comments (initial)
Changeable muscle tone? *

YES NO
Comments (initial)
Dislocated hip(s)/ other joint problems? *

YES NO
Comments (initial)
Vertigo, blackouts, nausea? *

YES NO
Comments (initial)
Hernia/ prolapsed? *

YES NO
Comments (initial)
Open wound(s)? *

YES NO
Comments (initial)
Gastrostomy? *

YES NO
Comments (initial)
Incontinence? *

YES NO
Comments (initial)
Tracheostomy? *

YES NO
Comments (initial)
Recent serious illness/ surgery? *

YES NO
Comments (initial)
Tender/ fragile skin? *

YES NO
Comments (initial)
Implant (e.g. Baclofen pump)? *

YES NO
Comments (initial)
Are there any other conditions of which we should be aware?
NAME OF ADULT COMPLETING THE FORM *
PROFESSION OR RELATIONSHIP TO PARTICIPANT *
I give my consent for the person on this form to take part in Rebound sessions and I understand that it is my responsibility to inform the session organisers of any changes to the participants condition
Signature *

Clear
Date *
Should be Empty: