Student Health Intake Form (Mobile version)
Student Name:
*Emergency Contact Info (Name):
*Phone:
*Massage License Number & State of Licensure:
*Massage Liability Company & Policy number:
*Height: ft. in.
*Weight: lbs.
COVID-19 Health Information & Informed Consent
Since you will be both a learner in our classroom as well as a client "under foot" of our instructor and other students, the following info is required to help us protect everyone involved in your class, as well as those at the business hosting this class.
1. Have you had a fever in the last 24 hours of 100°F or above? (If this changes within 14 days of your scheduled training, please let your instructor know.)
Yes
No
2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? (If this changes within 14 days of your scheduled training, please let your instructor know.)
Yes
No
3. Do you now, or have you recently had, any chills, any new onset of muscle aches and pains, new loss of taste or smell, or new rashes or lesions? (If this changes within 14 days of your scheduled training, please let your instructor know.)
Yes
No
4. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? (If this changes within 14 days of your scheduled training, please let your instructor know.)
Yes
No
5. Can you exercise to get your heart rate and respiratory rate up without any problem? (If this changes within 14 days of your scheduled training, please let your instructor know.)
Yes
No
Consent for Treatment
To proceed with receiving care in the classroom, I confirm and understand the following (Initial in all places provided) I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.
I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 and other common contagions have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care.
I understand the 2/25/22 CDC Community Level tools regarding when to return to Indoor Masking depending on the county, and will wear face mask when the county level is considered "High" or "Red". I understand that I and other participants in the class have the choice to mask otherwise, unless the training location or host site is requiring masks regardless (explained later in this section.) If the county of the training location is considered "red" and high risk, then I agree to wear a mask while indoors at each Center for Barefoot Massage training location or hosted site, and whenever within 6 feet of any person during this class while outside, and I will be following PPE guidelines of the FSMTB. Surgical or K95 masks are recommended, cloth masks with at least 2 layers and a good seal are acceptable. I understand that some Center for Barefoot Massage training location(s) or hosted site(s) may require masking regardless of the current Community County levels as monitored by the CDC. I understand that any classes that require masking will state so in the course descriptions or pre-class emails from the instructor, and I agree to adhering to these precautions if I am in one of those classes.
I have been offered a copy of this consent form.
I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.
Student Name:
Signature:
Date:
Health Intake
Circulatory / Cardiovascular
PLEASE EXPLAIN ANYTHING CHECKED OR NOT LISTED
Nervous System
PLEASE EXPLAIN ANYTHING CHECKED OR NOT LISTED
Surgeries
PLEASE EXPLAIN ANYTHING CHECKED OR NOT LISTED
Musculoskeletal
PLEASE EXPLAIN ANYTHING CHECKED OR NOT LISTED
Digestive
PLEASE EXPLAIN ANYTHING CHECKED OR NOT LISTED
Respiratory
PLEASE EXPLAIN ANYTHING CHECKED OR NOT LISTED
Skin
PLEASE EXPLAIN ANYTHING CHECKED OR NOT LISTED
Reproductive
PLEASE EXPLAIN ANYTHING CHECKED OR NOT LISTED
Other
PLEASE EXPLAIN ANYTHING CHECKED OR NOT LISTED
PLEASE LIST ALL MEDICATIONS/SUPPLEMENTS
THERAPEUTIC AGREEMENT
I understand that the massage given in this learning environment is not a customized massage therapy session and is provided by a massage student learning a new technique. All health concerns listed above are true and thorough; I have not withheld information regarding my health history. I understand that breast massage will not be performed during my treatment while receiving. I understand that draping with a sheet will be used throughout my session except in the case of a clothed massage. It is my responsibility to voice any concerns and offer instant feedback to my therapist if pressure, pain, temperature sensitivities or any other comfort issues arise during my session.
Student Name:
Signature:
Date:
The Center for Barefoot Massage Cancellation Policy
The cancellation policy becomes effective once you sign up for class. By signing up for one of our classes, your 50% retainer or payment-in-full retainer serves as a commitment to training, that you agree to the Training and Use Agreement, and you agree to the Cancellation Policy.
Due to the emphasis on recieving strokes from another student as well as from the instructor during your time in class with us, all students must be healthy and able to receive deep tissue, myofascial bodywork. If you are currently pregnant, trying to get pregnant, have recently had breast/gluteal/calf implants and/or some select surgeries within the last 9 months, if you are currently undergoing radiation or chemotherapy, or if you are experiencing anything that would be contraindicated for a deep tissue massage, then we regret that you cannot attend the seminar at this time. Please attend after recovery and when receiving deep, prone-positioned massage is indicated for your health.
REFUNDS
There are no refunds on the 50% retainer/deposit fee. All sales final for attended classes.
CONTINUING EDUCATION CREDITS
You must be present for the entire course to receive NCBTMB Continuing Education credits – partial course hours are not offered. Any hours missed in class will need to be made up with the instructor, at their hourly rate. Any post-class support materials such as videos will not be provided until the hours are made up.
RETAINER TO RESERVE YOUR SPACE
Non-refundable retainers of a minimum 50% are required to hold your space in a class. We hold a spot in our small training centers for you. For this reason, if you cancel, all monies paid will be retained by the Center for Barefoot Massage to offset the loss of business to the instructor of the Center for Barefoot Massage. Your retainer will not be refunded if you cancel out of your selected workshop dates. Retainers cannot be transferred to other attendees. You must meet all prerequisites for each class within 15 days of the class, or you will be removed from the roster with no refund or Roll-Over option.
IF WE CANCEL
The Center for Barefoot Massage reserves the right to cancel a class up to 14 days before the start date. This may happen should there not be enough interest – class minimum is 4 students, or 6 for offsite/travel classes. In the rare event that a cancellation initiated by us happens, we will either refund all tuition paid towards the associated class or transfer your retainer and registration into the next class of your convenience (class must be taken within 18 months). Classes are not guaranteed to happen - as class minimums, pandemics, and life events may interfere. The Center for Barefoot Massage will always give ample notice to any party impacted by any class cancellation, and will follow the company cancellation policies.
DEADLINES FOR RESCHEDULING YOUR TRAINING:
- 30+ days prior to class start date: no fee or penalty. If you need to move to another class date or location for any reason, your retainer will be applied to another class offered by the Center for Barefoot Massage. You will need to reschedule yourself and attend a class within 18 months from the date you originally made a payment. All unused funds expire after 18 months of purchase.
- 16-29 days prior to class start date: a Roll-Over fee of $75 will be charged to your student account in order for your reschedule request to occur. Only in the event of an emergency with proper documentation of Covid19/illness, injury, pregnancy, death in the immediate family, or extreme weather prohibiting travel (where the airports and highways are closed) will your retainer will be allowed to be rolled over without a fee to a workshop at a later date. This special emergency consideration will be allowed one time at the discretion of the instructor, and proof must be provided in writing (including any doctors notes to show diagnoses or surgery) prior to the start of class. You will need to reschedule yourself and attend a class within 18 months from the date you originally made a payment. All unused funds expire after 18 months of purchase.
- 2-15 days prior to class start date: Late cancellations within this window may cause a forfeit of 50% of the Retainer Fee. Any notice in this window is not eligible for rescheduling to another class/date/location – unless the situation can be documented as an emergency as explained above, and provided in writing (including any doctors notes to show diagnoses or surgery) prior to the start of class. At the discretion of the instructor and/or Center for Barefoot Massage, if a documented emergency absence is approved, a $75 rollover fee may be charged instead of the forfeit of 50% of the retainer fee. You will need to reschedule yourself and attend a class within 18 months from the date you originally made a payment. All unused funds expire after 18 months of purchase.
- 2-day notice / No Show: any rescheduled request within 2 days of the start of class, or an absence without any notification to the instructor or the Center for Barefoot Massage will cause a complete forfeiture of any money paid to the Center for Barefoot Massage - unable to be used towards a future class.
TUITION PRICES
If the instructor is traveling to a location to teach this class, rather than teaching at their home base, then the tuition rate will be +$100 more than base tuition rates listed on the website. These rates will be reflected in your course registration.
FEES
- The "Roll-Over" fee is $75, and may be charged by the Center for Barefoot Massage, the hosting instructors local business, or may be withdrawn from any prepaid retainer on file.
- Although the retainer fee is non-refundable, any other returned transaction (for example, the tuition remainder if you happened to pay in full) will be less 10% for processing, bank and registration system fees.
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COVID-19 RELATED CANCELLATION CIRCUMSTANCES:
If you or someone in your household are showing COVID19 symptoms, then you will need to cancel your spot in class. Whether you let us know 6 days before class or 6 hours, your safety and well being (as well as that of our students and staff at the training centers) are the priority, and we will work with you. Proof of a positive PCR COVID19 test provided ASAP will be required for your tuition to be rolled over to another course. Refunds are not available.
Please make the effort to stay safe, get tested early, and practice CDC, WHO and state recommended guidelines to help prevent the spread of the Corona Virus.
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PLANE TICKETS & TRAVEL RESERVATIONS
Do not purchase non-refundable or penalty-with-cancellation plane tickets until the class has been confirmed that it will take place. Your instructor will know at the latest, 14 days before class. Contact your instructor to confirm that the class will be held before purchasing the aforementioned tickets. The Center for Barefoot Massage cannot be held responsible for fees incurred when canceling a class per our policy.
Student Name
Signature
Date
|
Jeni Spring, LMT |
Mary-Claire Fredette, LMT |
|
“The creative forces“ behind The Center for Barefoot Massage, LLC & FasciAshi Technique, February 21, 2017 |
The Center for Barefoot Massage Training and Use Agreement
By attending our training workshops you will be a part of our professional family. As such, we have quality assurance and maintenance considerations to uphold the professional standards of the industry, and to prevent unauthorized instructional programs based on content that we present. You do not have permission to teach Center for Barefoot Massage content, techniques, theory, approaches, present any form of barefoot massage with the use of overhead suspended strap(s) or reproduce any materials presented/provided in our courses. It is essential that the purity of this work and the high-quality teaching standards established for this curriculum be upheld and honored for the continued respect of this lineage, as well as for the growth and support of our loyal FasciAshi practitioners.
By taking this training, you agree to the following:
- That you are currently a Licensed Massage Therapist legally eligible to provide paid, professional therapeutic massage therapy services to the public in accordance with the laws in your state. Your massage license number and status will be verified by our staff. If your state is not regulated, then a transcript showing completion of a 200-hour entry-level massage therapy training program, as well as proof of professional liability insurance will be required. Failure to meet prerequisites within the 15-day cancellation period results in a forfeit of tuition retainer.
- The words "Certified" and "Certification" can get confusing in our industry: to help clean up the use of that word, we have retired the optional "Certification" process that existed prior to 2020. All attendees of any Center for Barefoot Massage class will be emailed a PDF diploma showing the number of Continuing Education hours/credits they earned, with the date, location and instructor of the class they attended documented. This diploma serves as proof of training as well as a Ce Transcript, useful for submitting to state massage and association boards for renewals - and it's also a very attractive acknowledgment of your achievements in training that can be framed and hung on a wall!
- This training does not qualify or certify you to teach myofascial ashiatsu barefoot massage, or any style of barefoot massage within any environment where you demonstrate to or train others in any capacity how to utilize these protocols, sequences, techniques, trade secrets, equipment use/design, or methods, including the suspended support strap used during a barefoot massage session. Attending our workshops or acquiring our materials does not qualify you, or give permission to teach or present FasciAshi or any style of barefoot massage/bodywork, and thus you will not imply that you are such, or any similar designation, in any format unless you have successfully passed our instructor training program that leads to status as a FasciAshi Instructor and has written consent from the creative forces behind The Center for Barefoot Massage, LLC.
- You will not photocopy, publish, reprint, share or broadcast any materials from the training, in part or in whole, without the expressed written consent of its copyright holder, The Center for Barefoot Massage, LLC. Audio and video recording, as well as photographs of the class materials or techniques, are not permitted in any workshop. You will not use the protocols and techniques within this training in any form of media without the expressed written consent of The Center for Barefoot Massage, LLC.
- If this agreement and our trust is broken, the following consequences may include, (butare not limited to) a Cease & Desist order, Ethics violation reports to affiliated professional boards/associations, financial damage claims, removal of access to any Center for Barefoot Massage support or future training, removal of Sole Provider directory listing, and our endorsement of your work will end.
Student Name
Signature
Date
|
Jeni Spring, LMT |
Mary-Claire Fredette, LMT |
|
“The creative forces“ behind The Center for Barefoot Massage, LLC & FasciAshi Technique, February 21, 2017 |
Liability Waiver
This agreement releases The Center for Barefoot Massage, LLC, it’s faculty, the host site and the associated business(es) of the training facility from all liability relating to injuries that may occur in FasciAshi continuing education courses, internship training, intensive seminars, and private mentorship. By signing this agreement, I agree to hold the aforementioned parties entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether injuries are caused by negligence.
Due to the emphasis on recieving strokes from another student as well as from the instructor during your time in class with us, all students must be healthy and able to receive deep tissue, myofascial bodywork. If you are currently pregnant, trying to get pregnant, have recently had breast/gluteal/calf implants and/or some select surgeries within the last 9 months, if you are currently undergoing radiation or chemotherapy, or if you are experiencing anything that would be contraindicated for a deep tissue massage, then we regret that you cannot attend the seminar at this time. Please attend after recovery and when receiving deep, prone-positioned massage is indicated for your health.
I also acknowledge the risks involved in providing and receiving barefoot massage and using the overhead support system in a learning environment. I understand that many of the strokes and sequences within the FasciAshiTM technique are designed to be received by persons who are thick muscled and weigh 50 - 100 pounds over the practitioner’s body weight. The risks in giving and receiving the FasciAshiTM technique for extended increments of time over a short period of days include, but are not limited to stiffness, soreness, redness, skin irritation, headaches, sinus congestion, bruises or any condition due to residual effects of giving and receiving deep tissue, trigger point, myofascial release and range of motion massage techniques.
I understand that any information provided regarding the installation of the overhead support systems constitutes as part of this disclaimer. The Center for Barefoot Massage, LLC and any of their instructors accepts no liability for my own installation of an overhead bar support system and suspension strap or for their use outside of this training facility.
I swear that I am participating voluntarily and that all risks have been made clear to me. Additionally, I do not have any conditions that will increase my likelihood of experiencing injuries while engaging in this activity.
By signing below I forfeit all right to bring a suit against The Center for Barefoot Massage, LLC or the host site and associated business(es) of the training facility for any reason. In return, I will receive continuing education hours for attending this course. I will also make every effort to obey safety precautions as listed in writing and as explained to me verbally. I will ask for clarification when needed.
Student Name
Signature
Date
|
Jeni Spring, LMT |
Mary-Claire Fredette, LMT |
|
“The creative forces“ behind The Center for Barefoot Massage, LLC & FasciAshi Technique, February 21, 2017 |
Model Release
This Agreement is between The Center for Barefoot Massage and the following persons:
Name of therapist or client:
I hereby grant to Photographer (designated by onsite Center for Barefoot massage staff), her legal representatives, heirs and/or assigns, those for whom Photographer is acting, and those acting with his/her authority and permission (collectively “Photographer”), the absolute right and permission to copyright and use, re-use, and publish, photographic portraits or pictures of me or in which I may be included, in whole or in part without restriction as to changes or alterations from time to time, in conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium at his/her studios or elsewhere, and in any and all media now or hereafter known, for art, advertising, trade or any other legal purpose. I also consent to the use of any printed matter in conjunction therewith.
I hereby waive any right that I may have to inspect or approve the finished product or products or the advertising copy or printed matter that may be used in connection therewith or the use to which it may be applied.
I hereby release, discharge and agree to hold harmless Photographer from any and all liability that has or may occur or be produced in the taking of said pictures or any subsequent process thereof, as well as any publication thereof.
I acknowledge that I am at least 18 years old, and have the right and ability to consent to the terms herein, and further, that I am authorized and able to sign on behalf of all persons listed above as Model(s).
I have read, understood, and agree to the terms of this Release. I understand that I am or may be giving up certain legal rights by signing this Release.
Please select one:
I agree to the Model Release.
I prefer to opt out of the Model Release.
I prefer to opt out of the Model Release BUT I am OK with participating in the group/class picture
Student Name
Signature
Date
I have been offered a copy of this consent form.