In-person intensive and parent workshop sign-up form

Child's name

Parent name

Email Address

Phone Number

Parent Occupation

Address

Would you like to add another parent/caretaker to attend the workshop? Would you like to add another parent/caretaker to attend the workshop? Add another Parent/Caretaker

Parent 2 / Caretaker name

Parent 2 / Caretaker Email Address

Parent 2 / Caretaker Phone Number

Parent 2 / Caretaker Occupation

Language spoken at home

Referred by

What are your child’s diagnosis and challenges?

What can your child do (e.g. gross and fine motor skills, speech, social skills)?

What do you hope to see in your child’s development in the short and long term?

Please describe any illness, injury, or musculoskeletal problem or pain that has required medical attention?

Please check any of the following that apply to your child: Please check any of the following that apply to your child: Allergies/Asthma/Sinus Bone Joint Disease Cardiovascular/Heart Chronic Pain Diabetes Digestive Dizziness Headaches High/Low Blood RR Respiratory/Lungs Scoliosis Seizures Constipation Skin Disorders Vision problems Other medical conditions

Please read and check the boxes next to the following agreements: Please read and check the boxes next to the following agreements: I understand that the lessons given by the Feldenkrais®/ABM® NeuroMovement Practitioner (hereafter the “Practitioner”), are a way to open doors to new possibilities of movement and development, and are educational only. They are not medical and do not take the place of appropriate medical care. I agree to let the Practitioner know immediately if I see my child experiencing discomfort or pain. I affirm that I have notified the Practitioner of all known medical conditions and injuries of my child and will inform him/her of any changes in my child’s health and medical condition.

Parent 1 - print your name

Date

Parent 2 - print your name

Date