TERMS AND CONDITIONS

These are the terms and conditions on which we supply childrens yoga, mindfulness and massage classes to you ("the services"). They explain what you can expect from us and what we can expect from you.

Other applicable terms. The following additional terms also apply:

Our privacy policy, which sets out the terms on which we process any personal data we collect from you, or that you provide to us. By using our site and making a booking you consent to such processing and you warrant that all data provided by you is accurate.

Our cookie policy, which sets out information about the cookies on our site.

Our terms of use of the website (paragraph 16 below) which tells you the terms of use on which you may make use of our website, whether as a guest or a registered user.

Why you should read them. These terms tell you who we are, how we will provide services to you, how the contract may be changed or terminated, what to do if there is a problem and other important information that you need to be aware of. If you do not understand something in these terms, you must tell us immediately and we will seek to clarify the same.

Acceptance of these terms. By booking or by your child attending a children yoga or massage lesson with us, you hereby accept these terms and conditions and the cost that is attributed to the lessons provided. Payment will be taken via card at the time of booking through our online booking system. You will ensure that your child will follow general class session yoga and massage rules and any rules that are specific to a particular venue that we may use. If you do not accept these terms you must not use our website or make any booking.

Kalma childrens yoga, mindfulness and massage classes are based on yoga inspired stretches which parents/carer are encouraged to do with their children or children are encouraged to do themselves. Our sessions make yoga fun with serious developmental benefits, in a relaxing, informative and structured environment. We follow EYFS and SEN guidelines whilst incorporating song, music, and sensory props for stimulation! We create a wonderful bonding experience for parents/carer and children, offering breathing, mindfulness, relaxation techniques in classes too. Classes are kept active depending on age groups, with parent/carer stretches in baby and toddler classes, lots of partner stretches and group stretches included too.

INFORMATION ABOUT US AND HOW TO CONTACT US

Who we are. We are Kalma Baby and our office is at St Peters Gate Charles Street SR6 0AN.

How to contact us. Our preferred method of communication is by email info@kalmababy.co.uk .This allows us to deal with your enquiry promptly. You can also contact us by telephone on 07951490757 or by writing to the above postal address. Please note that our office hours are between 9am and 5pm on Monday to Friday, we are closed on Saturdays, Sundays and English Bank Holidays.

How we may contact you. If we have to contact you, we will do so by telephone or by writing to you at the email address or postal address that you provided to us when you registered at whatadoddle.co.uk

Your contact details. Please ensure that your contact and payment details are kept up to date. If your details change at any time, you must update your account at whatadoddle.co.uk. We are not responsible for any incorrect contact or payment details submitted by you.

"Writing" includes emails. When we use the words "writing" or "written" in these terms, this includes emails.

You are able to amend your contact and account details through your own individual account by logging on to the booking system and making the necessary changes. If you require us to change the named account holder on the booking system, we must receive the request in writing from the original account holder. The party the account is changing to must be included in all correspondence. They must share with us their contact details, and consent to the change separately from their own contact address. Any outstanding balances must be settled prior to any change over we make by the original account holder. Any changes made by us will not be made during a term. When we have received your request, we will notify you of the date of change prior to the start of the new term. The new account holder must follow the rebooking deadline to guarantee a space for the forthcoming term. The new account holder must also accept these terms and the terms of our privacy policy. If the rebooking deadline has passed when the request is received, the account will be changed prior to the start of the next term thereafter. If there are 2 or more students attached to the account and you wish to separate the account to more than one Customer, the above procedure must be applied, giving details of which Customer will be the account holder for which Student. Any request will be for the subsequent term, as outlined above.

OUR SERVICES

What we do. We offer professional yoga, mindfulness and massage services to children and adults of all ages and abilities. For more information, please visit our website at http://kamababy.co.uk

Types of lessons. Childrens yoga-Kalma Baby, Toddler and Junior, Childrens Mindfulness-Kalma Minds, Childrens massage-Kalma Massage, Holiday sessions-Kalma Kamps, School, nursery and sure start sessions. Your baby can start yoga from 6 weeks providing they have had their health check. Classes are split into age groups and can be attended depending upon age and development.

Class age groups are:

Kalma Baby Developmental Massage classes 6-8 weeks to crawling

Kalma Baby classes 6 weeks to 6 month (approx.) or sitting up UNAIDED

Kalma Baby classes 6 month (approx.) or sitting up UNAIDED to crawling

Kalma Toddler classes crawling or 9/10month to 2 years walking

Kalma Toddler classes 2-3 years walking toddlers

Kalma Pre-school classes 3-5 years (approx.)

Kalma Junior classes 5-8 years

Kalma Junior Classes 9-12 years

Schools and Nurseries Kalma Juniors and Kalma Minds

The following Health disclaimer must be read: As far as I am aware, I have disclosed to my Yoga/Massage teacher all information regarding my health and my child’s health relevant to the practice of Yoga/Massage on my child. I will seek advice from a Medical Practitioner for any health issues with either myself or my child before participating in any Kalma classes. I understand that if I am or become pregnant I will inform my Yoga/Massage teacher and partake in Kalma classes at my own risk. I take full responsibility for all applications of Yoga/Massage I may practice outside the Kalma classes both now and in the future. Any uses to which the recommendations, ideas and techniques are put are at my sole discretion and risk. I accept that Kalma Baby does not take responsibility for any applications of yoga/massage practices described or shown in books and videos. Any health issues your little one or self-have must be disclosed in the booking form under allergies/health issues section or to your yoga teacher including being pregnant. I fully understand that the recommendations, ideas and techniques expressed and described in Kalma classes, as well as in books and videos endorsed by Kalma Baby, cannot be regarded as a substitute for the advice of qualified medical practitioners. I understand that on occasions it may be necessary for my Yoga/Massage teacher to handle my child and I give full consent to this. I take full responsibility for my child during any Kalma classes.

How long are the classes and terms? Baby and Toddler sessions are 45-60 minutes. Some school sessions vary from 30 minutes to 60 minutes. Massage 60 minutes, Mindfulness classes 20 minutes, Mindfulness workshops 90 minutes. We run term time for rolling terms. Once a term is completed you can attend continuously-booking is advised in advance to secure your place. Children and or parents should arrive five minutes before the class starts.

What to wear and bring along? Comfy clothes on parents is advisable along with comfy non restricting clothes on your little one in babay and toddler classes. In Kalma Junior classes children should wear loose non restricting clothing or PE kits within schools. Socks for parents and all children as there are no shoes on the yoga mats shoes must be off. Bring a small blanket or muslin for your little one to lay over the cushion in baby classes.

Kalma Baby Privacy Policy: When you book a session you will be required to provide certain data concerning you/the child you are booking for. This may include the following information: a) Parent/Carer/Customer name, address and contact information including email address and phone number b) Emergency contact details c) Childs name and date of birth d) Any allergy or relevant health information about the child e) Whether or not you provides consent for photographs. We use the information gathered for : a) Session planning and ensuring that all children are booked onto an age appropriate session b) Health and Safety and Child Protection reasons c) Internal record keeping d) We may use the information to improve our products and services e) We may periodically send promotional emails about new products, special offers or other information which we think you may find interesting using the email address which you have provided f) From time to time, we may also use your information to contact you for market research purposes. We may contact you by email, phone, fax or mail. We are committed to ensuring that your information is secure. In order to prevent unauthorised access or disclosure, we have put in place suitable physical, electronic and managerial procedures to safeguard and secure the information we collect online. We will not sell, distribute or lease your personal information to third parties unless we have your permission or are required by law to do so. You may request details of personal information which we hold about you under the Data Protection Act 1998 and ask us to delete that data too. You can view our full privacy policy at https://www.kalmababy.co.uk/privacy-policy/ and request a copy of our Data Protection Policy by contacting us using the contact details on this site. Each branch is its own franchise entity. From time to time when franchise branches are sold on or when maternity or sickness cover is in place there is a need to transfer customers details to other teachers we will do this with the strictest confidentiality following all data protection policies. Kalma baby Ltd remains the over all data protection officer and franchise branches data controllers.

We will ask for pupil information when booking with schools and nurseries such as name, DOB, Health conditions. We will ask the same information in Sure Start Centres. This is an insurance requirement.

Photo Permissions: From time to time we may take photos in classes of your child and yourself. We allow photos to be taken by parents/carers during sessions but ONLY of YOUR own little one-we ask for the respect of other parent’s wishes of their children and that they are not photographed nor placed on media sites. The photos we take will be put into a closed private Facebook group you may request to be added at any time if attending classes please ask your teacher. They may be used on the official Facebook page and website or for any other marketing campaigns we may run, by booking this place you are giving permission for this. We regret that parents or outside spectators cannot take photos from our private group and must ask permission from the franchise owner to do so. Photos must not be shared with any third parties for child protection reasons. Photo permissions in schools will be asked for and will be respected.

Discount: A sibling/twin discount is given if attending of one full price one half price, please email in advance for information. Regretfully once Kalma Baby classes are booked no refunds can be issued due to missed sessions for any reason or due to not being able to no longer make a term. No refunds can be issued for holidays or sickness. No sessions can be rolled over. We operate a refer a friend scheme please ask a franchisee for more details.

Our acceptance of your booking. Our acceptance of your booking for the Course will take place once you have submitted the correct information in your online customer account including payment card details. You will receive notification that it has been successfully completed. If you place a booking and do not receive confirmation of successful completion within 2 hours of placing your booking, please let us know. Please check your spam folder for this.

If we cannot accept your booking. If we are unable to accept your booking, we will inform you via your online account or by email and will not charge you for the services.

ONLINE ACCCOUNT

Creation of Account. In order to book our services, you will have to create an account. You will log into your online account with the email address that you gave us as part of your registration process. You will be responsible for keeping your account password secure and confidential. You must notify us immediately of any breach of security or unauthorised use of your account that you become aware of.

You must keep your contact details in your online customer account up-to-date because we use this information for our re-enrolment process and to contact you if lessons are cancelled.

We will send you newsletters, re-enrolment letters and updates via the email address provided to us on your online account. You may only be unsubscribed from these notifications when you no longer take up our services.

We have the right to disable any account, at any time, if in our opinion you have failed to comply with any of these terms and conditions.

YOUR RIGHTS TO MAKE CHANGES

If you wish to make a change to the services or transfer classes, please contact us. We will let you know if the change is possible at the discretion of the teacher. If it is possible, we will let you know what effect this will have on the price, timing or anything else which would be necessary as a result of your requested change. We will also ask you to confirm whether you wish to go ahead with the change. We operate as a franchise brand and regretfully no classes can be transferred to other branches once booked.

If you wish to make a change to your online account, you can do so by logging on to the booking system. Reference 2.6 for more information.

PROVIDING THE SERVICES

When we will provide the services. We will supply the services to you for the duration of the session or course as set out in the booking.

Cancellation by us. If we determine that there is insufficient support for a session or course, we have the right to cancel, suspend or postpone the session or Course before the date of the first lesson. We shall give you as much notice as possible of any such cancellation and we will provide you with a full refund of your session or course fee. We may also offer an alternative lesson. Our liability for any such cancellation shall be limited to this refund and we shall not be liable for any losses of any kind incurred by you as a result of such cancellation.

Reasons we may suspend the services. We will make every effort not to cancel lessons once a Course has started but on rare occasions venue closures or other unforeseen circumstances may force us to do so. We shall give you as much notice as possible of any such cancellation. Our liability for any such cancellation shall be limited to this credit and we shall not be liable for any losses of any kind incurred by you as a result of such cancellation. The credit will be made within 14 days of the date on which we agree that you are to be credited to your payment method. We may offer another class or add this to the end of term.

We ask that you commit to your lessons as development is most often seen in lessons that are regularly attended.

IF THERE IS A PROBLEM WITH THE SERVICES

If you are at all unhappy with the service we provide please follow our complaints procedure:

Speak to the teacher, telephone or email a written complaint to the branch. The branch owner will try to resolve the matter to your satisfaction.

If the response is not satisfactory a written complaint should be submitted for the attention of the Office Manager at the head office at St Peters Gate Charles Street Sunderland SR6 0AN

PRICE AND PAYMENT

Where to find the price for the services. The price of the services (which includes VAT) will be the price set out in our price list in force at the date of your booking unless we have agreed another price in writing. You can access our price list online at whatadoddle.co.uk. We use our best efforts to ensure that the prices of services advised to you are correct. However please see clause 10.2 to see what happens if we discover an error in the price of the services you book.

What happens if we get the price wrong. It is always possible that, despite our best efforts, some of the services we sell may be incorrectly priced. We will endeavour to correct this.

How you pay.

Customers pay by card via our online method stripe or pay a monthly direct debit fee. Please reads below in terms of which method is applicable to your payment.

Where to find the price for the services. The price of the services will be the price set out in our price list in force at the date of your booking unless we have agreed another price in writing. You can access our price list online at whatadoddle.co.uk. We use our best efforts to ensure that the prices of services advised to you are correct. However please read all terms to see what happens if we discover an error in the price of the services you book.

Customers paying monthly direct debits. Customers pay by card via our online method stripe. Each time a payment is made you will be charged a booking fee which will be calculated as 3.9% +20p of the fee being charged

Your account will be credited by your direct payment, and your account debited by enrolment at the lessons based on the current class price, reduced by any credits that are on your account. This will show on your online customer account.

Insufficient funds or invalid card details

If sufficient funds are not available from your account on the agreed date, your card issuer may decline the continuous payment authority request. If your card issuer declines a payment, we will inform you by email that Doddle will make further attempts to take the payment at a later date. You should also contact us to agree an alternative repayment option.

You are responsible if you do not update your debit credit card details and they have changed. You can change your debit or credit card details at any time through your online account at whatadoddle.co.uk.

After the payment due date, if a recurring payment has failed, places are not guaranteed and will be offered to any customers waiting for a place in that class.

If a recurring payment has failed we may charge interest to you on the overdue amount at the rate of 1.5% a year above the Bank of England base rate from time to time. This interest shall accrue on a daily basis from the due date until the date of actual payment of the overdue amount, whether before or after judgment. You must pay us interest together with any overdue amount.

Re-enrollment and Cancellation

Should you wish to cancel your recurring payments and therefore future Group Lessons, we ask that you give us 28 days’ written notice (by email to your franchise branch where you are attending classes or by post) and we will cancel the direct payments. Based upon the credit accrued on your account we will then inform you of your final lesson date. You may use the model cancellation form set out at the end of these terms, but it is not obligatory. Your notice will only be valid when you receive written confirmation back from us.

Your account will be reconciled. Any money owed will be deducted from your current payment method, any money owed back to you will be credited. If you wish for this money to be credited to the bank account from which it came, please also state this in writing.

Failure to give 28 days’ written notice before your next payment is due to be taken will incur another monthly payment being taken. In addition to this you may also cancel your payments directly with your card issuer. If you have not contacted us to cancel, your place will be automatically re-booked on to the next Course and you authorise us to use the card details you have logged with us to debit the money due.

Payment as a one off by card. Each time a payment is made you will be charged a booking fee which will be calculated as 3.9% +20p of the fee being charged

Your account will be credited by your direct payment, and your account debited by enrolment at the lessons based on the current class price, reduced by any credits that are on your account. This will show on your online customer account.

Insufficient funds or invalid card details

If sufficient funds are not available from your account on the agreed date, your card issuer may decline the continuous payment authority request. If your card issuer declines a payment, we will inform you by email that Doddle will make further attempts to take the payment at a later date. You should also contact us to agree an alternative repayment option.

You are responsible if you do not update your debit credit card details and they have changed. You can change your debit or credit card details at any time through your online account at whatadoddle.co.uk.

Apart from those refunds referred to above you shall not be entitled to any refunds. If your child refuses to participate or you decide it’s not for you, or you decide you no longer want your child to attend the Course, we will not give refunds or credits. We try to arrange that your child has the same teacher for each lesson within the Course but we cannot guarantee this due to illness or holidays of the teacher and any unforeseen circumstances. You may not claim a credit or a refund due to a change in teacher or venue. We regret that we are unable to give refunds due to in adverse weather conditions where by venues can’t be accessed will we endeavour to add catch up classes where possible.

If you wish to query a payment or seek a refund please contact the relevant franchise branch where you are attending no refunds are issued from head office. We are able to review payment queries for terms which immediately precede the term we are currently in. If we are within our holiday dates then we will review payment queries for the term immediately preceding this. Reviews of payments are done on an individual basis and we will provide a written decision to you within 7 days of your original request or notify you if we expect the decision to be longer than this and therefore providing a revised response date. If a refund is deemed appropriate this will be processed within 14 days of written confirmation a refund is owed.

Increase in Prices. We may have to increase prices from time to time and this is at the discretion of each franchise branch and it’s owner. We will give you at least 6 weeks’ notice of any increase.

HOLIDAYS

When you are on holiday - In respect of the Group Lessons, if you wish to take holiday during a Course so that your child misses a lesson or lessons within the Course, you must still pay for the entire Course. You shall of course retain your place on the Course for the duration of the Course.

SICKNESS AND MEDICAL CONDITIONS

When the named student on your account is sick. If your child is ill, you can contact us via your online account on the day of the lesson. We will not provide refunds or credits for absence from booked lessons due to illness, regardless of the number of lessons missed as a result.

Long term illness.If your child suffers a serious illness affecting him or her for more than 4 weeks, we may at our franchise owners discretion offer you a credit or catch up class for all lessons missed if:

you inform us of the condition and prognosis no less than 48 hours before the first lesson to be missed;

you provide us with a doctor's note detailing your child's illness or medical condition;

we are able to find a replacement pupil for your child's place in the lesson.

You must declare to us in writing by logging into your customer account all medical conditions affecting your child, regardless of the severity.

If your child is experiencing chicken pox they must not attend lessons whilst they are still infectious. We suggest you are guided by a medical professional as to when it is safe to return to the class. Please bear in mind that although the infectious stage may be over, your child's skin may still be sensitive and therefore the massage or yoga movements may or may not aggravate this. As recommended by the NHS if your child has experienced diarrhoea please ensure that they do not return to classes for two days after the last episode of diarrhoea. This is a safe way to maintain cleanliness and hygiene in the classes and to limit the spread of infection. We would also advise a period of 48 hours break from classes if your child has experienced any vomiting or stomach upset. If your child experiences an ear or eye infection we suggest you seek professional medical advice on when your child is able to return to classes. Our brand adheres to the public health guidelines set out by the government as followed by all education sectors.

PARENTAL RESPONSIBILITIES

If you or a family member are spectating in the areas provided at your venue keep the noise levels to a minimum allowing the best communication to the class. It is a teachers discretion as to whether older siblings are able to attend to baby classes. There are many factors to consider and we ask that parents can be certain that they are able to watch them at all times as we have small babies inside the class, should this be allowed.

It’s a parents responsibility to be able to watch their toddlers during sessions. Any damages to any of our venues will be chargeable.

Mobile phones. We will not take responsibility if phones are lost or stolen. Please keep all valuables safe during classes.

OUR LIABILITY

We are not liable for damage to your property. We shall not be liable for any loss or theft of your or your child's personal possessions and all property left by you on the property is done so at your own risk.

We will take every reasonable precaution to ensure security and safety at our lessons, but we are not liable in any way for any loss or damage arising from our lessons or the venues that we use. However, nothing in these terms shall limit the liability of any person for death or personal injury caused by negligence.

As part of our structured lesson programme our Instructors use a variety of teaching methods to deliver our message. By accepting these Terms and Conditions you are agreeing to our Teachers being in the class with your child and at times where applicable may need to be in physical contact with them. The reasons for this are not exhaustive but do include, demonstration, guidance on how to deliver a yoga technique or safety. All of our Instructors are trained in line with statutory and company guidelines. This includes manual handling pertinent to the safe delivery of our lessons as well as an adherence to child protection policies and guidelines.

Venues including their property.It is your responsibility when you visit your designated pool to be mindful and respectful of its structure and contents. Please ensure if you notice any damage to the venue or its property that you notify the relevant party immediately. Any damage caused to the venue is not the responsibility of Kalma Baby. As a result all damage caused will be paid for by the individual concerned and Kalma Baby will not be liable for this. If the damage is due to fault by the property then they themselves will be liable for the cost of repair.

OTHER IMPORTANT TERMS

We may transfer this Agreement to someone else.We may transfer our rights and obligations under these terms to another organisation. We will always tell you in writing if this happens and we will ensure that the transfer will not affect your rights under the contract

Nobody else has any rights under this contract (except someone you pass your guarantee on to). This contract is between you and us. No other person shall have any rights to enforce any of its terms.

If a court finds part of this contract illegal, the rest of it will continue in force. Each of the paragraphs of these terms operates separately. If any court or relevant authority decides that any of them are unlawful, the remaining paragraphs will remain in full force and effect.

Even if we delay in enforcing this contract, we can still enforce it later. If we do not insist immediately that you do anything you are required to do under these terms, or if we delay in taking steps against you in respect of your breaking this contract, that will not mean that you do not have to do those things or prevent us taking steps against you at a later date. For example, if you miss a payment and we do not chase you but we continue to provide the services, we can still require you to make the payment at a later date.

Which laws apply to this contract and where you may bring legal proceedings. These terms are governed by English law and you can bring legal proceedings in respect of the services in the English courts.

How we will use your personal information. We will use the personal information you provide to us (about you and those of your child/children) to supply our services to you and process your payment for such services. We will need to pass your personal information to other third parties to process your payments. Any payment card details that you choose to save within our payment system will be held 100% securely by our payment processor ‘Stripe’. Your email address will be used to create your online account and for all communications. By providing us with an email address you are agreeing to receive communication from us by email.

TERMS OF USE OF SITE

Our sites.http://kalmababy.co.uk is a site operated by Kalma Baby LtD

Access to our sites are permitted on a temporary basis, and we reserve the right to withdraw or amend the service we provide on our sites without notice. We will not be liable if for any reason our sites are unavailable at any time or for any period.

Intellectual Property Rights.We are the owner or the licensee of all intellectual property rights in our sites, and in the material published on it. Those works are protected by copyright laws and treaties around the world. All such rights are reserved. You must not use any part of the materials on our sites for commercial purposes without obtaining a licence to do so from us or our licensors. You may not reproduce in any format (including on another website) any part of our sites (including content, images, designs, look and feel) without our prior written consent. If you print off, reproduce, copy or download any part of our sites in breach of these terms of use, your right to use our sites will cease immediately and you must, at our option, return or destroy any copies of the materials you have made.

No reliance on Information.The content on our sites is provided for general information only. It is not intended to amount to advice on which you should rely. Although we make reasonable efforts to update the information on our sites, we make no representations, warranties or guarantees, whether express or implied, that the content on our sites are accurate, complete or up-to-date.

Limitation of Liability

Nothing in these terms of use excludes or limits our liability for death or personal injury arising from our negligence, or our fraud or fraudulent misrepresentation, or any other liability that cannot be excluded or limited by English law.

To the extent permitted by law, we exclude all conditions, warranties, representations or other terms which may apply to our sites or any content on them, whether express or implied.

We will not be liable to any user for any loss or damage, whether in contract, tort (including negligence), breach of statutory duty, or otherwise, even if foreseeable, arising under or in connection with:

use of, or inability to use, our sites; or

use of or reliance on any content displayed on our sites.

If you are a consumer user, please note that we only provide our sites for domestic and private use. You agree not to use our sites for any commercial or business purposes, and we have no liability to you for any loss of profit, loss of business, business interruption, or loss of business opportunity.

We will not be liable for any loss or damage caused by a virus, distributed denial-of-service attack, or other technologically harmful material that may infect your computer equipment, computer programs, data or other proprietary material due to your use of our sites or to your downloading of any content on them, or on any website linked to them.

We assume no responsibility for the content of websites linked on our sites. Such links should not be interpreted as endorsement by us of those linked websites. We will not be liable for any loss or damage that may arise from your use of them.

You may link to our home page, provided you do so in a way that is fair and legal and does not damage our reputation or take advantage of it.

You must not establish a link in such a way as to suggest any form of association, approval or endorsement on our part where none exists.

You must not establish a link to our sites in any website that is not owned by you.

Our sites must not be framed on any other site, nor may you create a link to any part of our sites other than the home page.

We reserve the right to withdraw linking permission without notice.

Third Party Links.Where our sites contain links to other sites and resources provided by third parties, these links are provided for your information only. We have no control over the contents of those sites or resources.

Applicable Law.If you are a consumer, please note that these terms of use, its subject matter and its formation, are governed by English law. You and we both agree to that the courts of England and Wales will have non-exclusive jurisdiction. However, if you are a resident of Northern Ireland you may also bring proceedings in Northern Ireland, and if you are resident of Scotland, you may also bring proceedings in Scotland.

MODEL CANCELLATION FORM

(Complete and return this form only if you wish to withdraw from the contract)

To : Kalma Baby (branch name)

I/We [*] hereby give notice that I/We [*] cancel my/our [*] contract of sale for the supply of the following service [*],

Ordered on [*],

Name of consumer(s),

Address of consumer(s),

Signature of consumer(s) (only if this form is notified on paper),

Date

[*] Delete as appropriate

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