Sinead York Wellbeing Registration form

Sinead York Wellbeing/Relax Kids Belfast Registration Form

Thank you for your interest in my workshops or 1-1 sessions. Please fill in the form below. ****PAYMENT DETAILS ARE AT THE BOTTOM OF THIS FORM****** Your child's place is not guaranteed until payment and form is received. A deposit of £35 is required to secure 1-1 sessions.
What session is your child attending?
Parent/caregivers Name

First NameLast Name
Child's Name

First NameLast Name
Child's Age:
Child's Gender
Address

Street Address

CityState

Post code
The Oak Suite, 430 Upper Newtownards Rd, Belfast BT4 3GY
Mobile number
Primary E-mail
Emergency contact name
Emergency contact number
What issues do you feel your child needs help with? Eg: emotional regulation, confidence, resilience,etc. Give as much detail as possible. Or type None.
Does your child have a diagnosis of any kind, please give details or type none.
Does your child have epilepsy? If yes please advise coach as breathing exercises may trigger a seizure.
Does your child require an EpiPen if so please ensure you are in the building while sessions are taking place unless they are able to use it independently.
Does your child have any allergies?
Does your child have asthma? If yes, please advise coach and ensure they bring their inhaler.
Any other information I should be made aware of? Please state below.
How did you hear about Sinead York Wellbeing/Relax Kids Belfast?
Who will be picking your child up?
What are your child's interests/hobbies? This helps me tailor the sessions.
Do you give permission for Sinead to take photos of your child during the sessions. Their face can be covered if you prefer. Yes/No/Cover face.
Sinead York Wellbeing sessions may include movement, yoga stretches, visualisations, breathing exercises, mindfulness or EFT (Emotional freedom technique. Do you consent to your child being involved in these activities?
I consent to Sinead York Wellbeing using my email address for future marketing/blog post/offers?
I confirm that I have fully disclosed to Sinead York Wellbeing any or all conditions, physical behavioural or otherwise that my child has or may have before my child participates in the sessions?
Cancellation Policy
I understand that family life can be busy and that plans sometimes change.

If you need to cancel or rearrange your child's session, I kindly ask that you provide at least 24 hours' notice.

Appointments cancelled with 24 hours' notice or more can be rescheduled.
Appointments cancelled with less than 24 hours' notice, or missed without notice, cannot be rescheduled and the session will be lost.

Each appointment time is reserved especially for your child. As I am a small business, late cancellations and missed appointments leave appointment time that I am often unable to refill at short notice. Thank you for respecting my time and helping me continue to provide consistent support for children and their families.
Please confirm you have read and agree to the cancellation policy.
Signature.
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Sinead York Wellbeing Session Fees

2 x 50 min 1-1 SEAG Confidece sessions - £110.

2 x 50 min 1-1 Back to school/starting Y8 sessions £110

SEAG Group Session - 90 minutes £35 per child

Tailored 1-1 Sessions for emotional regulation/confidence/resilience

Phase 1: Building the Foundations - 3 x 50 minute sessions £195

Phase 2: Strengthening the Skills - 8 x 50 minute sessions £530

Phase 3 : Ongoing Support 50 minute top up sessions £65

Bank Transfer Details:

Sort Code: 40-47-68

Account Number: 74136462

Name on Account: Mrs S York

****Please leave your child's name as a reference when paying***

Any questions feel free to contact me on 07788 956562 or email relaxkidsbelfast@yahoo.com or via my website https://sineadyorkwellbeing.com
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Sinead York Wellbeing/Relax Kids Belfast Registration Form