Child's Details

Child's Full Name*

Child Date of Birth*

Child Gender*

Child Address (including postcode)*

Parent/Carer Details

Parent/Carer name*

Parent/Carer Tel Number*

Parent/Carer email*

Parent/Carer emergency contact and number*

Making the experience enjoyable!

How does your child communicate? For example: speech, sounds, smiles, signing?

Child's interests and likes.

Child's dislikes.

Is there any other information about your child you wish to share?

Additional Needs

(Only add information you feel is relevant otherwise leave blank)

Social / emotional / mental health / behavioural:

Physical:

ASC/Sensory Spectrum:

Hearing/Visual Impairment:

Any other information such as diagnosis or key professionals involved with your child (OT, Speech Therapist, etc)

Any allergies or intolerances from anyone attending:

Please give details of any medication you or your child are currently taking (if relevant):

Photo Permission

We would be grateful if you would give us permission to take photos of your child and use these in our printed and online publicity.

I give permission for Little Hiccups to take photographs and/or video of my child. I grant Little Hiccups full rights to use the images resulting from the photography/video filming, and any reproductions or adaptions of the images for fundraising, publicity or other purposes to help achieve the group's aim. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases and funding applications.

You have the right to opt out at any time.

YesNo

Electronic Signature

Asana (yoga posture) means posture easily held. If it’s too hard or if it hurts, you can stop! You may rest at any time during the class. It is important in yoga that you listen to your body and respect its limits on any given day.

I, the undersigned parent or guardian, certify that the above information is correct and understand that Yoga is not a substitute for medical attention, examination, diagnosis or treatment. In the case where my child has an injury, sickness or anything else that may be affected by physical activity, I have consulted with physician to ensure my child can take yoga classes. I recognize that is my responsibility to notify the instructor of any serious illness or injury before every yoga class.

I give my consent for my child to participate in the yoga sessions.

I also confirm that to the best of my knowledge (unforeseen circumstances aside) I will be able to attend all the sessions.

By submitting this form, I certify that the above information is correct, that I agree to promptly communicate any future changes to the above prior to the Yoga Assessment. Please speak to an instructor if you have any queries or concerns.

Please keep in mind that parent/carers are responsible for their child at all times.