Pilates Lesson
Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth:
/
Month
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Day
Year
Address
*
Street Address
City
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Alabama
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Zip Code
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*
-
Area Code
Phone Number
Current Occupation:
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Were you referred to Anointed Hands?
*
Yes
No
If yes, by whom?
Pilates Questions
Have you taken Pilates classes before?
*
Yes
No
What type of Pilates classes have you taken? Please check all that apply.
*
Mat
Apparatus
None
What do you hope to achieve through practicing Pilates?
*
Please describe any exercise or movement you do each week.
*
Health Questions
Describe your present physical health.
*
Excellent
Good
Fair
Poor
Please specify any areas of your body affected by injury, ailment or surgery.
*
Liability Waiver and Agreement
I have agreed to undergo instruction in the Pilates method of physical conditioning offered by Anointed Hands Massage and Pilates Studio. I have been advised and I understand that participation in the Pilates method and conditioning activities presents some unavoidable risk of injury, especially to people who have pre-existing injuries, illness or medical disabilities.
I understand that the use of exercise equipment also carries with it a risk of injury. I recognize that many changes may occur as a result of these exercises lessons, including possible short-term aggravation of some symptoms, feelings of tiredness, light-headedness, increased energy, and mood changes, etc.
I also understand that a medical evaluation is advisable before commencing any program of physical conditioning or exercise. I have and will continue to keep Anointed Hands Massage and Pilates Studio informed of any physical condition or disability which would prevent or limit any participation in an exercise or physical conditioning program. I acknowledge that although the conditioning program I participate in may have substantial benefits neither Anointed Hands Massage and Pilates Studio nor its instructors are engaged in diagnosing or treating medical diseases or deficiencies.
If I have agreed to undergo instruction in the Pilates method with a student intern, I have been advised that he/she has not yet completed the full requirements for certification. I understand that because the student intern has relatively limited experience with the Pilates method, the risk of injury to me may be greater.
I expressly assume all risks of my participation in the Pilates method of physical conditioning conducted at Anointed Hands Massage and Pilates Studio and waive any claim which I might otherwise bring against Anointed Hands Massage and Pilates Studio, its officers, directors, employees, interns and contractors as a result of injuries from or relating to my participation in the Pilates method.
Anointed Hands Massage and Pilates Studio will not be responsible or liable for any articles lost, stolen or damaged while at the studio.
I understand that mat and apparatus classes require prior evaluation of my fitness level and that I am responsible for attending the appropriate level class.
I have read the statement above and agree with all the policies.
*
I agree
I disagree
Today's Date
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