Optimal Health and Wellness
Registration for Leaps & Bounds
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Email address
*
Your email
Class (select one):
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Birth to 6 months (2 to 3 p.m.)
6 to 8 months (11 a.m. to noon)
14 to 24 months (10 to 11 a.m.)
24 to 36 months (3 to 4 p.m.)
8 to 14 months (1 to 2 p.m.)
Parent Name:
*
Your answer
Child's Name
*
Your answer
Child's date of birth:
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Your answer
Email:
*
Your answer
Phone Number:
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Your answer
What are you most interested in gaining from the class?
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Your answer
Do you have any concerns about your child’s development?
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Your answer
Will you have additional children in attendance? Age(s)?
*
Your answer
Are you a current patient at Optimal Health and Wellness?
*
Your answer
Are you interested in learning more about chiropractic care?
*
Your answer
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