Medical Form & Disclaimer - Hayley's Rose Retreat

Name *

Date of Birth *

Do you have child/children participating in the class with you? If this form is for just a child please fill in as normal, answering no to this question. *YesNo

Parent/Guardian's Name *

Relationship to child/children *

Child's Name *

Child's Date of Birth *

Add another child?

Child's Name

Child's Date of Birth

Street Address *

Apartment, suite, etc

City

County

Postal Code / ZIP

Country

Telephone *

Email Address *

Emergency contact name *

Emergency contact tel. no. *

Medical History

The following information is required to ensure your health. Whilst sessions may be practiced safely by most people, there are certain conditions that require special attention. If you are unsure, please consult your GP before commencing class. Please indicate in the boxes below whether or not you have any of the following medical conditions and then provide further information:

(THESE QUESTIONS ARE ABOUT YOU AND YOUR CHILD/CHILDREN, IF YOU ANSWER YES TO ANY OF THESE PLEASE PROVIDE DETAILS AND THE NAME OF WHO IT RELATES TO)

Any allergies, including food or drink? *YesNo

Please provide details

Any special requirements? *YesNo

Please provide details

Is there ANYTHING that may affect your participation in any session or recordings? *YesNo

Please provide details

Do you suffer ANY medical conditions/Injuries/Concerns in anyway/Or had any operations in the last 5 years? *YesNo

Please provide details

Are you on any medication or receiving any treatment for your condition?YesNo

Please provide details

Please confirm you take full responsibility for the health and wellbeing of yourself and child you care for when you participate in anything from Hayley’s Rose Retreat. *YesNo

Are you pregnant? *YesNo

How many weeks pregnant are you?

Have you had your first scan?YesNo

Is this your first baby?YesNo

Is there anything I should know about your previous pregnancies?

Have you recently had a baby? *YesNo

What is your baby's age? And any relevant information relating to your birth and postnatal conditions. Please also let us know if you had a c section.

Is there any health or any concerns with baby that would affect their participation in the class?YesNo

Please provide more details

Are you attending a pregnancy or post natal class *YesNo

Signature *

Print *

Date *

Parent/Guardian print on behalf of under 18 *

GDPR Statement -In order to comply with the General Data Protection Regulations, it is necessary for me to check whether or not you are happy for me to retain your contact details, and to send you information that I think may be useful to you, including training and events, and relevant updates (It is very minimal contact mainly regarding the sessions you have booked onto) To ensure that I only communicate with you with the contact details you have provided me above. I only hold information when it is necessary to do so in order for me to carry out my work. I aim to keep personal data on this form whilst you are attending my classes and for as long as is necessary thereafter. It gets stored in a locked box at the business address and if completed via the website it gets saved under password protect and kept secure within the business address. It will be disposed by deletion if via the website email or shredded if paper form. *Yes, please contact meNo, please don't contact me (please note that I won’t be able to contact you about any of the sessions you are booked onto)

Please confirm you will update Hayley’s Rose Retreat of any changes to your's or your child's medical history using the form provided via the website *Yes

Are you happy for teacher to correct or assist you or your children with postures by placing hands onto you *YesNo

Do you give permission for teacher to administer first aid on yourself or your child if medical assistance is needed? *YesNo

Signature *

Print *

Date *

Parent/Guardian print on behalf of under 18 *

Photo Consent - Every so often photos and/or videos will be used as part of publicity for any training programmes by Hayley’s Rose Retreat, seen via the website of Hayley’s Rose Retreat, on Hayley’s Rose Retreat social media platforms, Printed publications, newspapers, newsletters or exhibition packs. *I give consent to the usage aboveI do not give consent to the usage above

Signature *

Print *

Date *

Parent/Guardian print on behalf of under 18 *