New Baby Massage

Baby Massage

Join our fantastic free massage course for you and your baby aged 0-6 months
Our funders ask us to collect this information about everyone we work with. Please help us to keep these activities running. Rest assured that any information you provide will be kept confidential and your names or any identifying details will not be disclosed.
Name of parent *

First NameLast Name
Gender*

MaleFemaleNon-BinaryPrefer not say
Please tell us your age*

18-2526-3536-4546-5566+
Name of child*

First NameLast Name
Name of additional child

First NameLast Name
Baby's date of birth*

MonthDayYear
Date
Baby's sex*
Parent email*
example@example.com
Phone Number*
07987654321
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DIFFICULTY/DISABILITY/HEALTH PROBLEM Do you consider yourself to have any long-term disability, health problem or any learning difficulties?*

YesNo
EMPLOYMENT STATUS*

Full-Time employedPart-Time employedPensionerNot allowed to workUnemployed
Ethnicity*
Are you happy to be photographed for future promotion on Grand Junction's website and social media?*

YesNo
Have you been to Grand Junction before?*

YesNo
Have you ever attended a baby massage before?*

YesNo
Does your baby have any medical needs?*
Do you want your email added to our mailing list?*
Please sign to confirm that you can attend all six of the sessions*

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