New Client Form and Liability Waiver Name * First Name Last Name Email * Phone * (###) ### #### Birthdate * What are your goals for taking a personal Pilates session? * Do you have prior experience with Pilates? * Yes No Have you worked on the Pilates equipment before? * Yes No What sports and activities do you practice and how frequently? * Describe any physical injuries, surgeries, or discomfort. * Are you currently in pain? If so, describe the location, when it started, what triggers it, and what relieves it. * This section is for those assigned female at birth Are you currently pregnant? * Yes No If yes, please add your due date MM DD YYYY Have you recently given birth? * Yes No If yes, please add your date of delivery MM DD YYYY If you have recently given birth, did you experience any of the following? Cesarean Section Diastasis Recti Liability waiver * In consideration for being allowed to participate in the activities and programs offered by Elemental Pilates and its instructors, to use equipment and props in addition to the payments of any fees and charges, I do hereby waive, release, and forever discharge Elemental Pilates, LLC and the facility where classes and sessions are held from any and all responsibilities or liability from injuries or damages resulting from my participation in the above-mentioned activities. I understand and am aware that exercise is a potentially hazardous activity. I also understand that fitness activities involve risk of injury and even death, and I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I expressly assume and accept all risks. I hereby release and agree to hold Elemental Pilates and the facility where classes and sessions are held harmless from any causes of action, claims, demands, damages, costs, expenses and compensation for damage to myself that may be caused by any act, or failure to act, or that may otherwise arise in any way with any services received. I understand that this release discharges the aforementioned from any liability with respect to bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received. I also understand that I am solely responsible for ensuring that my physical environment is suitable for my participation in any session including the choice to wear a mask (if not required) or not during classes or personal sessions due to potential covid-19 or other infectious disease risks. This liability waiver and release extend to all owners, partners, and employees. I understand and agree Medical Clearance * We recommend you consult with a physician before starting this or any exercise program. If you experience any pain or discomfort during the course of the program, stop exercising immediately and seek medical attention. Pre natal and post natal clients must consult with their physician and have received verbal clearance to perform physical exercise. I understand and agree Terms and Conditions * All personal sessions are 60 minutes and have a 24- hour cancelation policy. If you do not call or e-mail the studio within 24 hours of your appointment, you will charged the full rate. Sessions are non-transferable and non-refundable. I understand and agree Electronic Signature Consent * By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. I understand and agree Electronic Signature * Please type your full name First Name Last Name Thank you and we look forward to working with you!
