Consent Forms

Parent & Child Massage Class Registration Form

Class Dates:

Class Location:

Class Time:

Cost:

Payment method:

Child’s Name:_______________________________________ Birthdate:_____________________

Caregiver’s Name(s) : ______________________________________________________________


Address:_________________________________________________________________________

City:_________________________________________________State:___________Zip:_________

Phone:________________________ Cell/Pgr:________________________

Email: ___________________________________________________________

Referred By:_______________________________________________________

Why are you interested in learning infant massage?

____________________________________________________________________________________________________

Is there any relevant information about the pregnancy, child birth, about you or the child, that I should know?

____________________________________________________________________________________________________

Do not attend class if:

You or your child is not feeling well


Your child has a temperature (fever)


Your child has had recent immunizations (within 48 – 72 hours prior to class)

If you have any questions prior to class, please feel free to contact me via my contact information below.

All my best!

Cynthia "Cindy" Scott LMT/Tx #122542, BCTMB, CLT, CPMT, COMT

[email protected]

www.cindysmassage.com

MTCINDY-143 (682)463-9143

Parent & Child Massage Class Lessons | Consent Form

Massage therapy for an infant/child is not intended to replace other forms of healthcare. Used as a form of adjunctive healthcare, potential benefits for the child include:

Skeletal:

- Aids in supporting good posture and balance

- Reduces muscle tension that could lead to potential medical problems

- Increases nutrient flow to bones

Muscular:

- Relieves muscle tension and spasm

- Aids in removal of lactic acid & carbonic acid which build up after strenuous activity

- Increases the flow of blood and nutrients to muscles

- Can increase or decrease muscle tone depending upon amount of pressure

- Can reduce or increase joint mobility depending upon amount of pressure

Digestive:

- May relieve constipation

- May relieve gas

- Reduces water retention

Cleans the blood by toning the kidneys

Circulatory:

- Stimulates blood and lymph circulation

- Helps strengthen the immune system

- Releases toxins held in the body

Respiratory:

- Improves breathing patterns

- Helps reduce respiratory problems

- Relieves tension in the chest allowing the lungs to expand more fully

Nervous:

- Relaxes and calms baby

- Helps baby to sleep

- Raises endorphin levels, promoting healing

- Provides a safe and easy release from frustration and hyperactive behavior

- The Vagus Nerve is stimulated influencing food absorption hormones (Insulin & Glycogen)

Child’s Name:_____________________________________ Birthdate:_____________________


Caregiver’s Name : ______________________________________________________________

Address:_______________________________________________________________________

City:________________________________________________State:___________Zip:_______

Phone:_______________________ Cell/Pgr:____________________

Email: ___________________________________________________________

Referred By:_______________________________________________________

In case of emergency.

Name: _____________________________________ Phone:________________

My healthcare provider is:

________________________________________________ Phone:________________

Infant/Child Massage is contraindicated if the child:

Has High Fever/Temperature

Has an acute infection, staph infection, illness or disease

Has a skin disorder which may be contagious or cause inflammation

Has open sores or lesions

Has had recent immunization/vaccination (wait 48 – 72 hours)

Has any life threatening medical condition

Has an unhealed umbilical cord (tummy massage contraindicated)

Has swollen lymph nodes

Has blood clots or a blood condition

Has diarrhea or other sickness

Common Precautions for Infant Massage include:

Apnea

Bradycardia

Tachycardia

Abdominal Distention

Gastrointestinal or Jejunostomy feeding tubes

Hydrocephalus

Inflammations

Edema

Dysplasia

Hemophilia

Jaundice

Recent Surgery

HIV/AIDS

Tumors

Cancer

Seizure Disorders

Please indicate any of the high risk factors, complications that I should be aware of:

Is there other relevant information about the pregnancy, child birth, about you or the child, that I should know?

Please list any health conditions or medication for infant/child:

_______________________________________________________________________________________________________

I, ______________________________, understand that I will be participating in infant massage therapy lessons as a form of adjunct health care.

I have noted above all complications, risks, or conditions my child has experienced AND I have obtained my child’s healthcare providers release.

I understand that I will be receiving infant massage therapy lessons as a form of adjunctive health care only and that it is not a substitute for other healthcare provided by a medical doctor or other licensed provider.

I hereby release and hold harmless and defend the practitioner (Infant Massage Teacher) from any claims, liability, demands and causes of action from my and my child’s participation in this therapy.

Signature:________________________ Date:________ Print Name:_____________________

Teacher’s Signature:__________________Date:________ Print Name:_____________________