Parent-Infant Skin-to-Skin Contact Consent Form
Please complete this form to provide your consent for participating in a parent-infant skin-to-skin contact session. Your information will be used solely for the purpose of this session.
Full Name of Parent or Guardian
*
First Name
Last Name
Relationship to Infant
*
Please Select
Mother
Father
Legal Guardian
Other
Infant's Full Name
*
First Name
Last Name
Date of Session
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you previously participated in a skin-to-skin session?
*
Yes
No
Signature of Parent or Guardian
*
Submit Consent
Submit Consent
Should be Empty: