Intake Form, Policies, & Waiver of Liability

Participant Name *
Participant Name
Birthday *
Birthday
Address *
Address
Home Phone *
Home Phone
Cell Phone
Cell Phone
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
Physician's Name *
Physician's Name
Physician's Phone *
Physician's Phone
Personal Goals
Number the following exercise benefits according to their importance to you ( 1 = most important, 10 = least)
Muscular-Skeletal Condition
Please list all injuries & surgeries. Check all body parts that are involved where appropriate.
Specify Right or Left. Please indicate the year of incident, and if physical therapy was performed.
Do you suffer from any other following conditions?
I will receive information and instruction while participating in the class, health program or workshop offered by Pilates of Pasadena LLC. I recognize that this class will require physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. 1. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in this class or any other activity associated with Pilates of Pasadena LLC. I represent and warrant that I am physically fit and have no medical conditions that would prevent my full participation in the class, health program or workshop. 2. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I may incur as a result of participating in the program. 3. I knowingly, voluntarily and expressly waive any claim that I may have against Pilates of Pasadena LLC, instructors, employees, independent contractors, and Maria Jimenez for injuries or damages that I may sustain as a result of my participation. 4. Heirs, my legal representatives and I forever release and waive any liabilities against Pilates of Pasadena LLC, Maria Jimenez, and its instructors for any injury or death incurred by my voluntary participation in this class, workshop or activity. Purchase & Cancellation Policies • Advance payment is required to sign up for classes. Appointments can be made online, at the studio or by phone. • Please arrive on time for scheduled classes. Each selected scheduled 55-minute session will begin on time. If you are late, your training session will not be extended past the time it was originally scheduled to end. • No refunds on purchase of classes. Classes are transferable once purchased. • We require a 24 hour notice on any cancellations or no-shows. Otherwise, a class is subject to full charge. • A $25 fee is assessed for returned checks Studio Policies. • If you choose to wear shorts, we require that undergarment legging style shorts be worn. No shoes are allowed on the Pilates Studio floor. We have wipes available for your feet. If your feet are dirty, please wipe them before entering the exercise area. • The studio is an open space that is shared with other instructors and clients. Please be mindful of conversation level. • Please limit the amount of perfume/cologne you wear out of respect for others. • For safety reasons, do not start any part of your workout until your trainer is present. I HAVE READ THE ABOVE RELEASE AND WAIVER OF LIABILITY AND FULLY UNDERSTAND THEIR CONTENTS. I VOLUNTARILY AGREE TO THE TERMS AND CONDITIONS STATED ABOVE. By submitting this form, you acknowledge that you have read the above release and policies. Thank you so much for your time! See you in the studio!
Date
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