Welcome to ALIGN WELLNESS STUDIO
Welcome to ALIGN WELLNESS STUDIO
Confidential Client Information
Name_____________________________________________________________________________
Male Female
Start Date____________________________________________________
Street Address_____________________________________________________________________
City_______________________State________________________________Zip_________________
Email Address______________________________________________________________________
Phone Numbers: Home_______________Cell__________________Work____________________
Birthday (m/d/y)__________________ Occupation______________________________________
Emergency Contact/Phone________________________________Relationship______________
How did you hear about us? ____________________________________
You are joining us for: Nutrition Pilates Reiki Massage Meditation Tai Chi Other
Tell us about your goals at Align____________________________________________________
____________________________________________________________________________________
Health History. This is confidential and important for your safety
Please list all medications___________________________________________________________
Pregnant? N/Y
Weeks?_______(Beginning Pilates while pregnant is not recommended)
Do you smoke? N/Y
List other forms of exercise and how often ___________________
____________________________________________________________________________________
_
Have you had any broken bones or undergone surgery in the last 5 years? Y/N
Please
explain_______________________________________________________________________
Pre-existing injuries or conditions that may limit your ability to
exercise___________________________________________________________________________
__
Please circle and explain
Lower back pain
Asthma
Headache/Migraine
Knee pain
Cancer
Sciatica
Balance issues
High Blood Pressure
Other
Hip or knee replacement
Vertigo
Shoulder pain
Scoliosis
Align Studio Client Waiver & Release
ALIGN CLIENT WAIVER & RELEASE
WAIVER & RELEASE: In consideration of the acceptance of Individual's participation in a Training Program (the “Program”), Individual
hereby waives any liability ALIGN may have arising out of my participation in the Program. Furthermore, I have been given the rules and
regulations of the Program, and as an Individual, Individual hereby agrees to hold harmless ALIGN and all other persons and entities, including
but not limited to any facility owner/operator utilized during the Program and all sponsors, individuals, third parties, clients, teachers, trainers,
Certified PPI Instructors, Senior Instructors, and the like involved in or otherwise connected with the Program for any damages, physical,
personal or property, which may arise from my participation in the Program. Because physical exercise can be strenuous and subject to risk of
serious injury, ALIGN urges you to obtain a physical examination from doctor before participating in the Program or participating in any
exercise activity. Individual agrees that by participating in physical exercise or training activities, you do so entirely at your own risk. Individual
agrees that Individual is voluntarily participating in the Program and these activities and use of facilities and premises and assumes all risks of
injury, illness, or death. ALIGN also is not responsible for any damage to or loss of your personal property and is in no way responsible for the
safekeeping of my personal belongings while I am in the studio. Individual acknowledges that Individual has carefully read this “Waiver &
Release” and fully understands that it is a complete release of liability. Individual expressly agrees to release and discharge all trainers, instructors,
other Individuals, officers, directors, employees from any and all claims or causes of action and Individual agrees
to voluntarily give up or waive any right that Individual may otherwise have to bring a legal action against any of the foregoing for personal
injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release also covers and includes
negligence and any legal theory based upon negligence. If any portion of this release from liability shall be deemed by a Court of competent
jurisdiction to be invalid and/or unenforceable, then the remainder of this release from liability shall remain in full force and effect and the
offending provision or provisions severed here from. By signing this release, Individual acknowledges that Individual understands its content
and that this release cannot be modified orally.
If under 18 years of age: As legal guardian of __________________ _____________, I consent to the above condition.
Signature: __________________________________________ Date: __________________
Name: _____________________________________________ [PLEASE PRINT]
ALIGN services are nonrefundable. If you are unable to complete your package before
its expiration, please contact us.
Pilates Packages expire in 4 months
Yoga Packages expire in 3 months
Please silence your cell phones in the studio
I have read and understand all studio policies.
Signature_______________________________________________________________________
Date___________________________________________________________________________
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