Infant Massage Registration Parent 1 Full Name* First Last Parent 2 Full Name First Last Name of any other support person joining you for this program: Name Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 1 Phone Number*Parent 2 Phone NumberParent 1 Email Address*Parent 2 Email AddressWhat is the name of your baby(ies)?*What is the age of your baby(ies)?*Do you have any concerns or questions you would like to share?I understand that I am learning infant massage in order to share nurturing and compassionate touch with my baby. My comfort and my infant's comfort are critical, therefore I understand I can participate in the class at our own pace. I know that I can feed, change, and soothe my baby during the class and can follow my baby's lead.*YesNoI understand that the physical and mental exercises taught by the educator or performed by me in the class should not be construed as a substitute for medical examination, diagnosis, or treatment.*YesNoI understand the certified educators of infant massage are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness. The class offers support and guidance, not diagnosis or treatment.*YesNoIf I have questions about whether my baby should participate in an infant massage group program, I can ask my baby's pediatrician. I participate in this educational course on my own accord.YesNoPlease understand all correspondence for this course will be via email. If you need to reach out to your facilitator at any time before or during this course, contact email@example.com or 860-523-3715. If you have any questions or concerns regarding this, let us know below.