Pilates Form - Nourish Mind + Body

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Name
First Last
Sex
Date of Birth
Occupation
Sports/Hobbies
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Home)
Phone (Cell)
Email
Emergency Contact
Name
First Last
Relation
Phone

Does your work/sport involve any of the following?
Have you done Pilates before?
What is your previous experience with Pilates?
How long did you practice Pilates?
Are you, or could you be, pregnant now?
Due Date
Have you been pregnant in the last six months?
How was the baby delivered?
Do you have high blood pressure?
Is your blood pressure
Have you had major surgeries in the last 10 years?
Describe the surgery
Have you had surgeries in the last 2years?
Describe the surgery
Do you suffer from back of neck pain?
Are there any movements that cause you pain?
Are you taking any drugs or medications that may affect your ability to exercise?
If 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?
Important
Pilates 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 Form
I, _________________________________________ 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
Details
Type Name for Waiver
First Last
Signature of Participant
First Last
Date
MM slash DD slash YYYY
Payment and Cancellation Policy
Payment 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
MM slash DD slash YYYY

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Emergency Contact