client enrollment form
CLIE NT ENR O L L M E N T F O R M
PERSONAL DETAILS
Name: _________________________________________
Postal Code: ___________________________________
Date of Birth: ___________________________________
Phone Number: ________________________________
Sex: Male / Female
Mobile Number: _______________________________
Occupation: ____________________________________
Email: _________________________________________
Sports / Hobbies:_______________________________
EMERGENCY CONTACT DETAILS
Name: _________________________________________
Phone Number: ________________________________
Relationship: ___________________________________
Mobile Number: _______________________________
How did you hear about us?: _____________________________________________________________________________
Do we have your consent for:
Email Reminders
Newsletter Updates
ALL INFORMATION WILL BE TREATED IN THE STRICTEST CONFIDENCE.
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BACKGROUND & HEALTH
Does your work / sport involve any of the following? (please tick)
Sitting for long periods Driving
Lifting heavy weights
Standing
Bending
Any other repetitive action
Will this be the first time that you have practised Pilates?
Yes
No
If No, have you previously attended:
Studio
At home (book, DVD)
At other gym ______________________________
5-10
10-20
Number of classes attended:
0-5
20+
Has you doctor ever said that you have any sort of heart trouble or defect?
Yes
if yes, please note
_________________________________________________
No
Do you feel pain in your chest when you undertake physical activity?
Yes
No
Are you, or could you be pregnant now?
Yes
Have you been pregnant in the last six months?
Yes
if yes, what’s your due date?
_________________________________________________
No
If yes, how was the baby delivered?:
No
Normal
Caesarian
Do you often get headaches?
Yes
if yes, please note
_________________________________________________
No
How is your blood pressure?
High
Normal
Low
Please let us know of any blood pressure medications: _________________________________________________
-2-
Do you experience fainting, dizziness or have you lost consciousness when exercising?
Yes
No
Have you had major surgery in the past 10 years?
Yes
Have you had minor surgery in the past 2 years?
No
Yes
No
if yes, please note
if yes, please note
_________________________________________________________________________________________________
Do you suffer from asthma, diabetes, or epilepsy?
Yes
No
Have you ever been told that you have arthritic joints, osteoporosis, or any bone or joint problem that may
be made worse by exercise?
Yes
No
Do you suffer from neck or back pain?
Yes
if yes, please note
_________________________________________________
No
Do you have pain or restricted movement in any other joints (e.g. hip, knee, ankle)?
Yes
if yes, please note
_________________________________________________
No
Have you been diagnosed as hypermobile (excessive joint mobility)?
Yes
No
Are there any movements that cause you pain?
Yes
No
Please list any drugs or medication you are currently taking: ____________________________________________
Have you been referred to Pilates by a specialist?
Yes
No
If yes, by your: GP
Osteopath
Physiotherapist
Chiropractor
Other ________________________________________
Do you hereby give us permission to contact them?
Yes
No
If yes: Practitioner’s Name: _____________________________
Phone Number: _________________________________
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Please list any health problems you suffer, not already mentioned, that may affect your ability to exercise. If you have
answered YES to any of the questions above, we advise that you consult with your medical practitioner before you start
Pilates classes. Please give further relevant details, in confidence, to any questions ticked YES below.
YOUR GOALS
What are your reasons for taking up Pilates?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
What health or physical goals would you like to achieve over the next three months?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
What longer-term health or physical goals would you like to achieve over the next 12 months?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
-4-
IMPORTANT INFORMATION
Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes.
It is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with your teacher. It is also wise to wait six weeks after the birth before resuming exercise.
Pilates exercises are very safe, however; with all forms of physical exercise, it is prudent to consult your doctor before
starting Pilates sessions.
These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of
the exercises, you should refer back to your medical practitioner. The teacher can accept no liability for personal injury
related to participation in a session if:
• Your doctor has, on health grounds, advised you against such exercise;
• You fail to observe instructions on safety or technique;
• Such injury is caused by the negligence of another participant in the class/studio.
Exercise should be performed at a pace which feels comfortable to you. PAIN is the body’s warning system and should
NOT BE IGNORED. Please inform your teacher immediately if you feel any discomfort during a session. Please also
inform the teacher if you felt any discomfort after a previous session.
I understand that The Pilates Tree exercises involve hands-on correction and I hereby consent for my teachers to work
in this way.
-5-
LIABILITY WAIVER
To the best of my knowledge, I am in good physical condition and fully able to participate in this Pilates course. I am
aware that with any type of physical activity there are risks and hazards connected with the participation. I hereby
voluntarily participate in said event, knowing that the associated physical activity may be hazardous to my property
and me. I voluntarily assume full responsibility for any risks or loss, property damage, or personal injury, that may be
sustained by me, or loss or damage to property owned by me, as a result of participation in this course.
I hereby release, waive, discharge and covenant not to sue Christine Waterman, Nicole Bruce or The Pilates Tree Studio,
their officers, servants, agents, and instructors (herinafter referred to as releasees) from any and all liability, claims,
demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including
death, that may be sustained by me, or to any property belonging to me, while participating in physical activity, or while
on or upon the premises where the even is being conducted.
It is my expressed intent that this release and hold harmless agreement shall bind the members of my family and
spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a
release, waive, discharge, and convention to sue the above named releasees.
In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability, understand it
and sign it voluntarily as my own free act and deed; no oral representations, statement or inducements, apart from the
foregoing written agreements have been made; and I execute this release for full, adequate and complete consideration
fully intending to be bound by same.
I will not advertise that I have been formally certified by Christine Waterman, Nicole Bruce or The Pilates Tree and
acknowledge that I am not certified to teach Pilates.
CANCELLATION POLICY
Cancellation of an Appointment
In order to be respectful of studio policies, please contact the studio if you are unable to attend a session. We ask that
you give us a minimum of 24 hours notice prior to your start time. This will give us some time to offer your spot to
another person.
How to Cancel Your Appointment
To cancel appointments please call 250-320-2639.
If we do not answer, please leave us a message or email us at [email protected]
Late Cancellations
Late cancellations will be considered as a “no show”. You will be automatically charged for the class.
Signature___________________________________________ Print Name __________________________________________
Date________________________________________________
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