Infant Massage Class Enrollment Packet

Maternal and Neonatal History
During pregnancy with this child, did the mother experience any unusual illnesses, conditions or accidents? Yes / No If yes, please explain:*
Length of pregnancy (weeks)blanks Duration of labor blank
Where was the child born? Type a label Type a label
Delivery was:*
Please describe any complications during labor or delivery: *
Birth weight blanks* Birth length blank*
Did your child require oxygen or a ventilator? Were there any breathing problems at birth? If yes, how long? *

General Medical Information
Does your child pass the newborn vision screening? If no, please describe:*
Did your child pass the newborn hearing screening? If no, please describe:*
Do you have any concerns about your child's hearing or vision? If yes, please describe:*
Has your child had any seizures/infantile spasms? If yes, what age did they start? Please describe:*
Is your child taking medicine at this time? If yes, what type, amount & time given?*
Has your child been hospitalized since their discharge from the NICU? If yes, please list hospital, date and reason.*
Has your child had any significant injuries or illnesses since discharge? If yes, please describe:*
Does your child have any stiffness in the arms or legs since discharge from the NICU? *
Does the child have allergies? Is your child allergic to latex? If yes, describe reaction(s):*
Is your child having any swallowing, feeding and/or nutrition challenges? If yes, please describe*
Is your baby having tummy discomfort, excessive spitting up or constipation? If yes, please describe:*

Developmental Profile

Fill in the approximate age your child began to:
Are there any daily routines that are challenging for your child? (Examples: feeding, sleeping, bath time, car seat travel, etc.)*
What helps your baby to calm or be happy? *
Have you noticed anything that consistently makes your child upset or overstimulated? *
Describe any major concerns you have for your child. How long have you had those concerns? You can also include any medical conditions you would like us to be aware of (O2, catheter, a NG tube, G tube, trach, etc.)*
How do you think our Infant Massage Class will help you the most? *
Who will be bringing your child to Infant Massage? *

Authorization to Disclose Information

Medical
Child's Name blanks
I, (parent's name) blank, 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)
Allergist
Audiologist
Cardiologist
Cerebral Palsy Specialty Clinic
Children's Rehab Services
Dentist
Dept. of Pension & Security
Down Syndrome Specialty Clinic
Endocrinologist
Gastroenterologist
General Surgeon
Geneticist
Low Birth Weight Clinic
Mental Health Center
Neurologist
Neurosurgeon
Newborn Follow-Up Clinic
Nutritionist/Dietician
Nurse
Opthamologist
Orthopedist
Otolaryngologist (ENT)
Pediatrican*
Physiatrist
Physical/Occupational Therapist
Psychiatrist
Psychologist
Public Health Dept.
Social Worker
Speech/Language Pathologist
Spina Bifida Clinic
Signature*

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Authorization to Disclose Information

Early Intervention/Public School System
Child's Name blanks
I, (parent's name) blank, 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.
State EI Program
Service Coordinator
Special Instructor
Speech/Language Therapist
Occupational Therapist
Physical Therapist
Other Service Provider
Public School System
Signature*

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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.
Name of Child*

First NameLast Name
Signature of Parent/Legal Guardian*

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Picture and Information Release Form
I, (parent's name) blanks, hereby give The Bell Center for Early Intervention Programs and The Service Guild permission to use pictures or video of my child blank (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.
I DO grant permission for my child's name to be used with the child's picture for publicity. *INITIALS NEEDED (choose one or the other, not both)
I DO NOT grant permission for my child's name to be used with the child's picture for publicity. *INITIALS NEEDED (choose one or the other, not both)
Parent/Guardian Signature*

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General Information