Mommy and Me Wellness Program

PLEASE NOTE: Please make sure you fill out this form prior to class. If you have any questions involving payment or class time please contact our staff by texting us at 954-282-1347

First Name:

Last Name:

Mobile Phone Number:

Email:

Child’s Name:

Child’s DOB:

Class Selection:

Has your participating child or children suffered any of the following?
DiabetesHeart DiseaseChest PainsCancerAnemiaShortness of Breath/ Difficulty BreathingBroken BonesOsteoporosisAsthmaAllergiesHeart MurmurThyroid ProblemsLung ProblemsKidney ProblemsPneumoniaEpilepsyTachycardiaHeart AttackRecent SurgeryPalpitationsHigh Blood PressureLow Blood PressureSeizuresFaintingDepressionNo Medical Problems or Issues

Please list any other medical illnesses or problems or type NONE:

How did you hear about us?
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Acknowledgement:
I, acknowledge my participating child or children and I have been cleared by our respective physicians to participate in physical exercise and wellness classes.

My physician, and my child’s/children’s physician, have provided clearance for participation in physical exercise and wellness classes.

Photo/Video Release:
By checking this box, I agree for Jump Start Physical Therapy and Training and Lindsey Bragg, PT, DPT to use photos of myself and my child/children for marketing purposes via print, social and other media.

By submitting this form I certify that if any concerns arise during my or my child’s participation in these classes or after, I will notify the instructor immediately.

I hereby certify that the statements here are true, correct, and accurate as of the date of the signing of this document. If during the course of your child’s participation in this program any answer changes, you will immediately inform us of the changes.

Type Name

Today’s Date:

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