Health & Safety Questionnaire

Before you and/or your child participate in My Little Place of Calm mindfulness and meditation course please fill out and sign the following form in order to check for suitability. All information given here is confidential.

Child's full name*

Date of birth*

Child's age*

Address*

Parents email*

Parents name*

Tel number*

Emergency contact number (if different)*

Have your and/or your child participated in a meditation/mindfulness class before?

YesNo

If yes please provide details

Are there any particular issues you would like to highlight prior to your child attending a meditation/mindfulness class (for example, lack of confidence, sleeplessness, anxiousness, inability to relax or concentrate)?

Please list below any allergies (including food), illnesses, injuries, or medical conditions that you feel I should be made aware of prior to starting the class, (for example epilepsy, asthma, heart conditions)?

If your child suffers from any illness, injury or physical disability and you are unsure whether they should participate in a meditation/mindfulness class, then please check with your Doctor.

Tick here to say that you have consulted a doctor and received permission if necessary.

YesNo

Permission to take photographs during the class to use for promotion materials.

YesNo

DISCLAIMER

If at any time during the class, you feel discomfort or strain, gently come out of the meditation posture. You may rest at any time during the class. It is important that you listen to your body and respect its limits on any given day. I, the undersigned, understand that meditation and mindfulness is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including meditation and mindfulness. I recognise that it is my responsibility to notify my teacher of any serious illness or injury before every class and/or workshop. I accept that neither the instructor, nor the hosting facility, is liable for any injury, or damages, to person or property, resulting from my child, or me and my child taking part in the class.

Please type your name to give your consent here:

Would you like to receive information via your email on upcoming workshops and events, new videos, blogs and anything new and exciting coming up.

YesNo

(You will be able to unsubscribe at any time from my emails)

Thank you

Michelle x
Chilled Out Child Facilitator Training Programme