Breathe and Play November Mini Series

Breathe and Play November Mini Series

Dates: November 23rd, November 24th, and November 25th
Please fill out the form below.

If you have any questions please email amanda@breatheandplaywellness.com
Name of Parent/Guardian

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Child

First NameLast Name
Child's Age
Does your child have an IEP or 504 plan?
Does your child have any medical conditions, injuries, or allergies that we should be aware of?
Emergency Contact Number #1:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Number #2:
Please enter a valid phone number.Format: (000) 000-0000.
Photo Release (check one)
Would you like your child to participate in our walking companion program? We can pick your child up from school and walk over to Church in Bethesda. Please note that we will cross 1 road together.
Liability waiver and Consent Form

Please read and review the following terms and conditions.
I understand participation in Breathe and Play (movement, mindfulness, breathing exercises and related activities) involves physical activity and risks, including possible injury.

I confirm that my child is able to participate. I agree to inform instructors about any health concerns that may affect participation.

In consideration for my child's participation, I voluntarily assume all rishks and release Breathe and Play Wellness (owners, instructrors, and volunteers) from liability for injury, loss, or damages arising from participation, except in cases of gross negligence or intetnional misconduct.

I authorize emergency medical treatment for my child if I cannot be reached and understand I am responsible for any related medical costs.
I have read and understand this waiver and voluntarily agree to its terms.

My Products

November Mini Series (all 3 days)

Select this option if you'd like to sign your child up for all 3 afternoons.

$185.00

November Mini Series (Monday and Tuesday only)

Select this option if you'd like to sign your child up for Monday and Tuesday series ONLY

$140.00

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Breathe and Play November Mini Series

Please fill out the form below.

Liability waiver and Consent Form

My Products