Registration Form | Rock–A–Bye Babies-Expressions Academy

First Name

Last Name

Email

Phone Number

Date of Birth

Address

Class or Workshop Attending

Rock–A–Bye Babies

How did you find out about us?

Have you been diagnosed with a heart condition and advised not to take part in physical activity?

Yes

No

Do you have chest pain brought on by physical activity?

Yes

No

In the past month, have you developed chest pain when not doing physical activity?

Yes

No

Do you lose your balance as a result of dizziness or lose consciousness?

Yes

No

Do you have a bone/joint problem that could worsen by a change in physical activity?

Yes

No

Has a doctor ever recommended medication for your blood pressure or a heart condition?

Yes

No

Are you aware through your own experience or from doctor’s advice or any other reason why you should not do physical activity?

Yes

No

Please outline any other relevant information that may affect your ability to exercise: known allergies, pre-existing medical conditions, current medication etc.

If you select ‘YES’ in response to any of the questions above, you may need your GP’s consent before participating in a Rock-A-Bye Babies class.

Name of Emergency Contact

Phone Number of Emergency Contact

Is this your first pregnancy?

Yes

No

Have you experienced any complications during pregnancy, birth or post-partum?

Yes

No

If yes, please give more detail:

What type of delivery did you have?

If 'other', please specify:

Have you had any of the following? Please tick those that apply

Premature birth

Large baby (8lbs+)

Multiple birth

None of the above

Did you tear or require an episiotomy?

Yes

No

Have you been given the postnatal 6 week check by your midwife or doctor?

Yes

No

Have you been given permission to exercise by your midwife or doctor following your postnatal check?

Yes

No

Are you continuing to see your midwife?

Yes

No

I have read, understood and completed this questionnaire. I understand that it is my responsibility to read and follow the manufacturer’s guidelines for my sling/carrier and that I need to ensure it is safe for use for my child

I understand that it is my responsibility to monitor mine and my baby’s physical condition at all times. I agree to take part in this class at my own risk and Expressions Academy CIC will not be responsible for any injury or loss or harm of any kind

Do you consent to your data being added to our database for communication purposes, eg information about future events and newsletters:

Yes

No

If Yes, please circle how we can communicate with you:

Email

Text Message

Phone call

Do you consent to your data being added to our database so we can use your details at future events (and prevents the need for additional forms to be completed)

Yes

No

Do you give permission for Expressions Academy to record and use video footage or photographic images of yourself for website, social media and future advertising.

I do give permission

I do NOT give permission

Date of form completed and submitted:

Registration Form | Rock–A–Bye Babies

About You

Emergency Contact

About Your Birth

Please tick to acknowledge:

Contact with Expressions Academy