Self-Healing Class Student Waiver
PARENTS/GUARDIANS: Please fill out this entire form for each minor who will be attending one of our classes.
Email address *
Todays Date *
Student's full name *
Student's date of birth *
Student's email address
Student's Phone number
What are your child's plans after the class each week? (required for MBCS) *
Student will walk to after-care.
Student will be picked up by parent or carpool.
Student will be walking home.
After class on 3/21
After class on 3/28
After class on 4/4
After class on 4/11
Permission to contact student *
Name of Parent/Legal Guardian *
Physical Address
Parent preferred contact number *
Parent email
Ok to text? *
Parent preferred form of contact *
Class student will be participating in
Clear selection
Does this student have any allergies? (if yes, describe) *
Does this student have any physical limitation? (if yes, please describe) *
Comments or Notes about your student I need to know
Please check boxes to confirm you have read and understood statements and then type full name below to sign electronically.
I have read and signed the Disclosure form here: *
I give permission for my student to attend self-healing classes with Keslie. I understand that my student will be learning and participating in several alternative healing methods and modalities, not limited to Reiki, energy healing, chakra balancing, essential oils, crystals, meditation, and journaling. *
Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless, Keslie Mack Pain Coaching, from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with self-healing class(es). *
I'd like to be added to your mailing list for information on adult classes, other services offered and upcoming events. *
I prefer to pay: *
By typing your full name below you are electronically signing form. *
A copy of your responses will be emailed to the address you provided.
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