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. -1- 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: _________________________________ -3- 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________________________________________________ -6-
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