One to One Booking Form 121 Booking Form To book a 1 to 1 session, please complete the following sections and make your payment using the details provided at the bottom of the form. Data Privacy*To book a 1 to 1 session,, I require your contact details and your baby's medical information. Your details will remain strictly confidential and will not be passed to any third parties. By submitting this form, you are consenting to being contacted with information about similar classes and treatments. Please check the Privacy Policy to see how your data is protected and managed: https://www.thehappylittlebabycompany.co.uk/privacy-policy/ I consent to my submitted data being collected and stored. Name of Parent/Carer* First Last Child's Name* First Last Your Relationship to Child*Child's Date of Birth* Date Format: MM slash DD slash YYYY Phone Number*Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address* Do you or your child have any medical conditions or allergies?* Yes No If yes, please provide detailsDid you / the baby's mother experience any issues during pregnancy?How was the birth for you / the mother and baby?Did the birth include any of the following?ForcepsVentouseCaesarean-sectionPrematureInductionHave you / the baby's mother experienced any issues postnatally?What are your current concerns about your baby?Are there any areas of your child's body they do not like being touched?What do you hope to gain from these sessions?*How did you hear about Happy Little Baby classes?*Search engineLocal flyer or posterSocial MediaExisting clientMagazine articleWord of MouthOtherPaymentPlease send your course fee via bank transfer to: Victoria Thomas Account no 79922834 Sort Code 09-01-27 (PLEASE USE YOUR NAME AS THE REFERENCE)Parent Declaration*I understand that the techniques learned are not considered to be a medical aid and therefore I must ensure that my child is also receiving appropriate care from a primary care provider if relevant. I realise the work is being given for the wellbeing of my child. I have stated all medical conditions that I am aware of and will update the practitioner of any changes in my child’s health status. I give consent for my data to be stored on the understanding that they will be in a secure place and kept confidentially. I can ask for them to be deleted at any time. Confirm Signature of Parent / Carer*
