Enrolment Form

EveryBaby is a 6 week program designed and run by physiotherapists promoting healthy postnatal development for both mum and baby. It will include gentle postnatal yoga, early development exercises and multi disciplinary education sessions.

Cost:

$35 per session. Participants will be required to pay for the 6 week program upfront. Participants are able to claim through the private health insurance if they have physiotherapy cover.

Location:

EveryKid Clinic; 8/142 James Ruse Drive, Parramatta. Entry off River Road West.

When:

9am to 9:45am Tuesdays; 6 week block

Who:

Mums and bubs from 6 weeks to 9 months old

Contact Details

Mother's First Name: *

Mother's Surname: *

Mother's Date of Birth: *

Contact Email: *

Contact Number: *

Emergency contact name and relationship to contact: *

Emergency contact number: *

Child's Details:

Child's First Name: *

Child's Last Name: *

Child's Date of Birth: *

Gender: *

Birth Weight: *

Birth Length: *

Birth Head circumference: *

Current Weight: *

Current Length: *

Current Head Circumference: *

APGAR Score? *

Gestational age (if born prematurely)

Type of feeding: *e.g. breastfeeding, bottle fed with breastmilk, formula, mixed

Do you have any concerns with feeding? *

Do you have a family history of any hereditary or genetic conditions? *

Medical History

Previous or current medical conditions: *Please list NA if not applicable

Previous surgeries in the last 5 years: *Please list NA if not applicable

Is this your first child? *

YesNo

If no, what is the birth order of your child?

Did you have any complications throughout your pregnancy or delivery? *e.g. preeclampsia, preterm labour

Pelvic History

Do you currently have or have a history of pelvic pain? *

YesNo

If yes, please specify?

Do you currently have or have a history of incontinence (urinary or faecal) *

Yes No

If yes, please specify?

Do you currently have or have a history of pelvic organ prolapse? *

YesNo

If yes, please specify?

Do you currently have or have a history of sexual dysfunction or pain? *

YesNo

If yes, please specify?

Do you have currently have or have a history of abdominal separation? *

YesNo

If yes, please specify?

Musculoskeletal History

Do you currently have or have a history of back pain? *

YesNo

If yes, please specify?

Do you currently have or have a history of hip pain? *

YesNo

If yes, please specify?

Please list any sprains, strains and or fractures that you have obtained in the past 5 years or that might affect your participation in the class? *Please state NA if not applicable

Lifestyle

What are you physical activity levels? *how many minutes and activity types

Current or previous occupation? *

Do you have any current exercise restrictions ? *as advised by a paediatrician, obstetrician or GP

Goals and Concerns

Do you have any concerns about your postnatal recovery? *

Do you have any concerns about your child's development? *

Publicity Consent

From time to time EveryKid performs marketing activities to generate support for our services. This is administered in the form of photos, videos, recordings and interview material through printed publication and social media. We will only use visual images and recordings that omit surnames, personal information and that have been taken with signed permission. It would be helpful if you allowed us to use such visual images and material of your child and family in our endeavours.

Please note, you reserve the right to withdraw permission at any time by contacting EveryKid.

I/We give permission for EveryKid to take and use appropriate visual materials (photographs, audio recordings and/or video footage) of my child/family for use in publications and promotional materials. Use includes, but is not limited to, EveryKid website, social media, marketing brochures and flyers, presentations made by EveryKid staff, submissions for funding and external publications related to, but not produced by, EveryKid.

Please indicate below if there are any exception to the above:

Signatory's Name: *

Signed *

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Today's Date: *

Service Agreement and Consent Form

I understand and hereby consent to myself and my child participating in the class offered at the clinic. I understand that the activities may involve physical movements and exercises designed to enhance parent-child interaction and development. *

I agree to inform the therapist, respectfully, if I wish to not participate in a particular exercise or activity or if I do not consider the exercise is appropriate or acceptable. *

I acknowledge that the class does not constitute medical advice and diagnosis. It is the participant's responsibility to obtain all necessary medical advice as they think is necessary in relation to the group class *

I acknowledge that EveryKid will collect information about me and my child for the purposes of providing appropriate services to you. We will not share the information with anyone without your knowledge or consent.
*

I hereby accept the terms as specified and commit to making full payment for the entire program in advance. I understand that refunds will not be made for any sessions that I am unable to attend. *

Signed *

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Signatory's name: *

Today's Date: *

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