Kashmir Hands Continued Education Intake
1. Full Name (as it appears on your massage license)
2. Professional Credentials (LMT, NCTMB, other certifications)
3. License Number
4. State of Licensure
5. Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
6. Email Address
example@example.com
7. Phone Number
Format: (000) 000-0000.
8. Emergency Contact Name & Phone
9. How did you hear about this course?
10. How long have you been practicing massage therapy?
11. What type(s) of massage do you specialize in? (e.g., Swedish, Deep Tissue, Prenatal, Reflexology, etc.)
12. What other certifications or skills do you have? (c.g., yoga, hypnotherapy, energy work, etc.)
13. Are there any areas or techniques you hope to improve or explore during this class?
14. Do you plan to bring your own massage table and sheets?
Yes
No
15. Will you require access to a table for shared use?
Yes
No
16. Do you have any injurics, physical limitations, or medical considerations that we should be aware of during hands-on practice?
PLEASE TAKE A MOMENT TO READ CAREFULLY THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED. THANK YOU.
If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary provider may be required prior to your service. I understand that massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I immediately inform the therapist so that the reassure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for a medical examination, diagnosis or treatment and that I should consult a physician or other qualified specialist for any mental or physical ailment that I am aware of. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep Dina Giugliano, Kashmir Hands Inc. therapists updated to any changes in my medical profile and understand that there shall be no liability on the therapists part should I neglect to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of scheduled appointment, class or service. Signature
Media Release Consent: I hereby grant Kashmir Hands Inc. and Dina Giugliano permission to use, publish, and display photographs, video recordings, or other likeness of me for educational, promotional, or advertising purposes in any form of media without additional compensation.Signature
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Participant Media Sharing: Participants are welcome to take photos or videos during the course with the consent of oneanother. Sharing your experience is appreciated and encouraged. If posting on social media, pleaseconsider tagging Dina Giugliano to help spread awareness of this specialized training and the impactof therapeutic touch. Massage therapy is a highly skilled profession that supports healthier, morebalanced living for the communities we serve. Signature
Social Media Tagging Consent: For the purposes of social media (including platforms such as Facebook and Instagram), pleaseindicate below if you give Kashmir Hands Inc. and Dina Giugliano permission to tag you in photosor vidcos. Signature
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