Infant Massage Parent Agreement

Parent/Guardian Agreement
Parent/Guardian Name

First NameLast Name
Second Parent/Guardian/Support Person (if applicable)

First NameLast Name
Child's Name

First NameLast Name
Birth Date

MonthDayYear
City/State

Street Addess 1

Street Address 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Educator's Name
Class Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.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.
Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Parent/Guardian Agreement