Infant Massage Parent Agreement

Parent/Guardian Name*

First NameLast Name

Second Parent/Guardian/Support Person (if applicable)

First NameLast Name

Check here if second parent/support person will be joining the class

Child's Name*

First NameLast Name

Birth Date*

MonthDayYear

City/State*

Street Addess 1

Street Address 2

CityState

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Educator's Name*

Class Date*

Date

I understand that I am learning infant massage in order to share nurturing and compassionate touch with my child/dependent. If my child or I experience any pain and/or discomfort during any of the class time, it is my own responsibility, and not that of the instructor to stop or slow down my/our activity.I understand that the physical & mental exercise(s) taught by the educator or performed by me in the course of the class(es) should not be construed as a substitute for medical examination, diagnosis or treatment, and I/my child or dependent should seek qualified medical assistance for any physical or mental ailment that I/we are aware of.I/We understand that certified educators of infant massage are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the class(es) should be construed as such.Because massage and/or exercise is contraindicated (should not be done) under certain medical conditions, I affirm that I have consulted my child's/dependent's health care professional prior to participation and/or I am participating with my child/dependent by my own choice in these classes/exercises. I understand that there shall be no liability on the educator's part, and that I am responsible to seek professional advice for my child/dependent for any reason.I understand that I am responsible for my/our own attendance, and that missing any portion of the class series does not grant me make-up courses.Photo & Media Release: I understand that my instructor may occasionally take photos or video during class for promotional purposes, such as for use on our website, social media, or printed materials. My participation in the class implies my consent to be photographed or recorded and for those images to be used, unless I communicate otherwise to the instructor before the start of class. The instructor will make an effort to ask before taking photos or video, but it is my responsibility to notify them if I do not wish to be included.I also understand that should I require further information about this instructor, I may contact Infant Massage USA® at www.infantmassageusa.org

Signature*

Date Signed*

Date

Parent/Guardian Agreement