Nia Health/Liability Waiver
Nia & MOVEit with Jennifer Hicks
PRIVACY AND CONFIDENTIALITY
We value your privacy. Please note that all information gathered via this form is transferred securely and is encrypted in storage. This process encodes information to prevent anyone other than its intended recipient from viewing it.
Date
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Year
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Month
Day
Pronouns
e.g., she/her; they/them
Full Name
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First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Emergency Contact Information - name, relationship, contact #, contact email
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Health Profile
Nia & MOVEit with Jennifer Hicks
Privacy, Confidentiality & Respect for your Personal Health Information
We value your privacy. Please note that all information gathered via this form is transferred securely and is encrypted in storage. This process encodes information to prevent anyone other than its intended recipient from viewing it. That said, your personal health information may feel tender and something you like to keep close to you. Please know that you can choose not to answer any of the questions below.
Are you taking any drugs or medication?
Please Select
Yes
No
Other (Please specify...)
If yes, which medication(s) are you taking?
Do you have high blood pressure?
Please Select
Yes
No
Other (Please specify...)
If other, please specify.
Have you every had a real or suspected heart attack or stroke?
Please Select
Yes - a real or suspected heart attack
Yes - a real or suspected stroke
Yes - both a real or suspected heart attack and stroke
No
Other (Please specify...)
If other, please specify:
Do you have frequent faint or dizzy spells?
Please Select
Yes - frequent faint spells
Yes - frequent dizzy spells
Yes - frequent faint and dizzy spells
No
Other (Please specify...)
If other, please specify:
Have you ever experienced a seizure?
Please Select
Yes
No
Other (Please specify...)
If other, please specify:
Do you ever experience blurred vision while exercising?
Please Select
Yes
No
Other (Please specify...)
If other, please specify:
Have you ever experienced shortness of breath, irregular heart beat or had pressure or pain in your chest as a result of physical activity?
Please Select
Yes
No
Other (Please specify...)
If other, please specify:
Do you have diabetes?
Please Select
Yes
No
Other (Please specify...)
If other, please specify:
Do you have a chronic illness?
Please Select
Yes
No
Other (Please specify...)
If yes, please explain.
If other, please specify:
Do you have a muscle, joint or back disorder that could be aggravated by physical activity?
Please Select
Yes
No
Other (Please specify...)
If yes, please explain.
If other, please specify:
Do you have advice from a physician not to exercise?
Please Select
Yes
No
Other (Please specify...)
If other, please specify:
Are you currently pregnant?
Please Select
Yes
No
Other (Please specify...)
If other, please specify:
Is there anything about your medical or health situation that you'd like to elaborate on? Do you have any physical or medical considerations that could impact your physical participation in Nia classes?
How did you hear about this class?
*
Please Select
Social Media
Internet
Magazine
Other (Please specify...)
If other, please specify:
Would you like to join my mailing list?
*
Please Select
Yes
No
Email messages are sent approximately 2x per month and contain schedule and special event information.
Waiver/Release
To the best of my knowledge the information produced herein is accurate. My participation in the Nia and/or Nia MOVEit class is voluntary and at my own risk. I release the Nia Technique, Inc. of any responsibility for any consequences arising form any activity I participate in provided by Nia Technique, Inc. or any Nia Trainers or Nia Teachers. I hereby release respective owners, instructors and assigns from any liability for any claims, demands, injuries, actions, or causes of actions to m y person or property arising out of connected with the use of any of the services, equipment or facilities provided by Nia Technique, Inc. or any Nia Trainers or Nia Teachers. I further understand the activities may involve strenuous exercise and risk of bodily injury and I accept full respsponsibility for any activity I engage in with Nia Technique, Inc. or any Nia Trainer or Nia teacher. I have carefully read with a full, definite and clear understanding the foregoing provisions and freely enter into the within agreement of the waiver/release.
By writing your full name below, you are agreeing with the full waiver/release above
*
First Name
Last Name
Image Release
I consent to you and your successor in interest, the use of my images (as they may appear in any still photograph, picture, film and/or digital media) for print, broadcast and or sale purposes in connection with and/or promotion for Nia Technique, Inc. and/or Associates. By placing my initials in the box below, I permit my image(s) to be used as stated above and grant full rights to Nia and Associates on an irrevocable and unlimited basis without any compensation or payment for any such use and further use thereof.
Initial below to permit image use
Final Signature Required
I have carefully read and understand the foregoing provisions. By writing my name below I hereby certify and acknowledge that I understand all terms of this contract and agree to be legally bound by the terms and conditions set forth in the specific provisions under which I have signed my initials.
By writing your full name below, you are agreeing with the full waiver/release above
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First Name
Last Name
Date
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Year
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Month
Day
Date
What are you most looking forward to from taking this Nia class?
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