REGISTRATION FORM FOR KIDS
Date of birth
Please list any conditions or symptoms your child is currently experiencing (physical, mental or emotional).
Birth information and position in family. Were there any complications?
Other complementary therapies currently used. If yes, how often?
Is there anything else you would like me to know about your child?
I give permission to Justyna Kubach to perform the role of the Facilitator in Breathing sessions. I understand that if my child has medical concerns it remains my responsibility to consult a medical professional and inform the Facilitator. I understand that my Facilitator makes no claim to benefit any specific condition and gives no guarantee as to outcome. I, intending to be legally bound, hereby agree and release from liability and indemnify and hold harmless, the Facilitator. I agree to accept financial responsibility for any costs or damages which might arise from participation in breathing activities. I agree to terms & conditions.
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