Relax Kids Belfast registration form

Relax Kids Belfast Registration Form

Thank you for your interest in my workshops or 1-1 sessions. Please fill in the form below. Places on each group session are limited to 8 so book early to avoid disappointment. ****PAYMENT DETAILS ARE AT THE BOTTOM OF THIS FORM****** Your child's place is not guaranteed until payment is received. A deposit of £35 is required to secure 1-1 sessions.
What session is your child attending?
Parent/caregivers Name*

First NameLast Name
Child's Name*

First NameLast Name
Child's Age:
Child's Gender*
Address*

Street Address

CityState

Post code
Mobile number
Primary E-mail*
Emergency contact name
Emergency contact number
What issues do you feel your child needs help with? Eg: emotional regulation, confidence, resilience,etc. Give as much detail as possible. Or type None. *
Does your child have a diagnosis of any kind, please give details or type none.
Does your child have epilepsy? If yes please advise coach as breathing exercises may trigger a seizure.
Does your child require an EpiPen if so please ensure you are in the building while sessions are taking place unless they are able to use it independently.
Does your child have any allergies?
Does your child have asthma? If yes, please advise coach and ensure they bring their inhaler.
Any other information I should be made aware of? Please state below.
How did you hear about Relax Kids Belfast?
Who will be picking your child up?
What are your child's interests/hobbies? This helps me tailor the sessions.
Do you give permission for the relax kids coach to take photos of your child during the sessions. They can be useful for showing what tools and techniques they are learning. These can be shared on social media as well as emailed to you.
Relax Kids classes may include movement, yoga stretches, visualisations, breathing exercises, mindfulness, and self massage. Do you consent to your child being involved in these activities?
I consent to you using my email address for future marketing by the Relax Kids coach
I confirm that I have fully disclosed to the Relax Kids coach any or all conditions, physical behavioural or otherwise that my child has or may have before my child participates in the class.
Signature.
Date

DayMonthYear
Date
To secure your child's place on a GROUP WORKSHOP could you kindly submit this form and pay the fee of £35 via the bank transfer details below.

OTHER SESSION FEES:

60 min 1-1 SEAG Confidece sessions - £55.

60 min 1-1 Back to school/starting Y8 sessions £50

3 x 60 min tailored 1-1 Sessions for emotional regulation/confidence/resilience £195

Bank Transfer Details:

Sort Code: 40-47-68

Account Number: 74136462

Name on Account: Mrs S York

****Please leave your child's name as a reference***

Any questions feel free to contact me on 07788 956562 or email relaxkidsbelfast@yahoo.com
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Relax Kids Belfast Registration Form