Pilates Form Step 1 of 2 50% Name First Last SexMaleFemaleDate of BirthOccupationSports/HobbiesAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone (Home)Phone (Cell)Email Emergency ContactName First Last RelationPhone Does your work/sport involve any of the following?Sitting for long periodsBendingLifting Heavy WeightsDrivingStandingAny other repetitive actionHave you done Pilates before?YesNoWhat is your previous experience with Pilates?How long did you practice Pilates?Are you, or could you be, pregnant now?YesNoDue DateHave you been pregnant in the last six months?YesNoHow was the baby delivered?Do you have high blood pressure?YesNoIs your blood pressureNormalLowHave you had major surgeries in the last 10 years?YesNoDescribe the surgeryHave you had surgeries in the last 2years?YesNoDescribe the surgeryDo you suffer from back of neck pain?YesNoAre there any movements that cause you pain?YesNoAre you taking any drugs or medications that may affect your ability to exercise?YesNoIf you were referred to me, by whom?What are your reasons for taking up Pilates?What health or physical goals would you like to achieve?ImportantPilates is very safe but, as 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 counseling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your practitioner. The teacher can accept no liability for personal injury related to participation in a session. Please advise me before commencing any session if, for any reason, your health or your ability to exercise changes. Exercises should be performed at a pace that feels comfortable for you. PAIN is a warning sign of the body and should NOT BE IGNORED. Please inform me immediately if you feel any discomfort during a session. Please also inform me if you felt any discomfort after a previous session. Yes Waiver of Liability and Prospective Release FormI, _________________________________________ hereby agree to the following: I am participating in physical activity at Nourish Mind + Body, LLC, with Audra Bursae, which may include, but is not limited to Pilates. I recognize that any physical activity may be strenuous and may cause injury, and I am fully aware of the risks and hazards involved in such activity. I represent and warrant that I am physically fit and I and have no medical condition that would prevent my full participation in these exercises. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in these classes or treatments. If I have any existing medical condition, I have been cleared by my doctor to participate doing Pilates with Audra Bursae and will explain the details below. In consideration of being permitted to participate in these exercises, I expressly assume the risks involved, whether or not such risks were created or exacerbated by the Instructor. I release Audra Bursae and Nourish Mind + Body, LLC, his/her heirs, executors, administrators and assigns, its officers, directors, shareholders,employees, teachers, lecturers, agents, health counselors and staff (collectively, the Releasees) from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law, admiralty or equity, which against the Releasees, I ever had, now has or will have in the future against the Releasees, arising from my past or future participation with Pilates, unless arising from the gross negligence of the Releasees. Myself, my heirs or legal representatives , forever release from liability, waive, discharge and covenant not to Audra Bursae, Nourish Mind + Body, LLC, the owners and its agents for any injury or death caused by any negligent act or omission. I have read the above release form and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. Yes DetailsType Name for Waiver First Last Signature of Participant First Last Date Date Format: MM slash DD slash YYYY Payment and Cancellation PolicyPayment is by check or cash only. Checks should be made payable to CASH or Audra Bursae. Audra Bursae and Nourish Mind + Body LLC accept no responsibility for personal items lost or stolen on the premises. PILATES SESSIONS: Cancellations made with less than 15 hours notice are charged the full rate of the session. Cancellations should be made over the telephone, not by email. All pre-paid packages expire in 3 months from purchase date and there are no refunds for any reason once sessions have been purchased. Yes Clients Name First Last Date Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.