Infant Massage Class Enrollment Packet

  • General Information

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  • Gender      Present Age   
    Present Height    Present Weight      

  • Reason for Referral/Diagnosis (if known)*
    Referring Physician * Pediatrician (if different)   * 

  • If you weren't referred by a physician or pediatrician, how were you referred to us? *

  • The information below refers to            
    Do both parents live in the home?         

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  • Employer/Profession   *  
    Work Phone*   
    Cell Phone   *   
    Email Address*   

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  • Employer/Profession   *   
    Work Phone*   
    Cell Phone   *  
    Email Address*   

  • Primary Physician/Pediatrician * Phone Number *
    Address   *   

  • Maternal and Neonatal History

  • Length of pregnancy (weeks) Duration of labor
    Where was the child born?         

  • Birth weight * Birth length *

  • General Medical Information

  • Developmental Profile

    Fill in the approximate age your child began to:

  • Authorization to Disclose Information

    Medical

  • Child's Name
    I, (parent's name) , hereby authorize the disclosure of information for the purpose of early intervention services from The Bell Center for Early Intervention Programs to the following medical professionals and/or others as indicated. (list name, facility & phone number)

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  • Authorization to Disclose Information

    Early Intervention/Public School System

  • Child's Name
    I, (parent's name) , hereby authorize the disclosure of information for the purpose of early intervention services from The Bell Center for Early Intervention Programs to the following medical professionals and/or others as indicated.

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  • Full Release and Waiver of Liability

  • In consideration for accepting the undersigned child into The Bell Center for Early Intervention Programs, and the providing of professional services to the undersigned child by the same, I, as the parent and legal guardian of the undersigned child, do hereby fully release and discharge, for myself, my heirs, legal representatives, and assigns, the following: The Bell Center for Early Intervention Programs, The Service Guild of Birmingham, Inc., and their agents, servants, volunteers, and employees from any and all legal liability or claims for money damages, compensation or indemnification, arising from, and by reason of, any and all known and unknown illness, injuries or damages, that may be suffered by the undersigned child due to or resulting from his/her participation or attendance in any activities or professional services provided by The Bell Center for Early Intervention Programs. This release incorporates as it fully set forth herein the Alabama "Volunteer Service Act." I understand that The Bell Center is not responsible for determining when medical procedures are needed for my child nor for the administration of any procedure nor the upkeep of any medical equipment. 

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  • Picture and Information Release Form

  • I, (parent's name) , hereby give The Bell Center for Early Intervention Programs and The Service Guild permission to use pictures or video of my child (name of child) for the purposes of promotion the program of services offered by The Bell Center for Early Intervention Programs. It is agreeable to use pictures or video for publicity and promotion purposes in newspapers, newsletters, magazines, brochures, bulletins and other publications and electronic forms distributed by The Bell Center and The Service Guild. I understand that in signing the forms, I release The Bell Center and The Service Guild of all liability in its actions under this permit.

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