Nicole Bennett Pilates

Nicole Bennett Pilates

Welcome! My mission is to empower you to be in control of you health and well being through the pilates method. To better serve your health and fitness needs, please take a few minutes to complete this form. All information is completely confidential and is collected only for the sole purpose of maximizing my ability to provide customized, comprehensive, and courteous service. Thank you for your cooperation!
What are you interested in?

Private Pilates Training
Name*

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Address

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Phone Number*

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Email*
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Emergency Contact
Have you taken Pilates before? if so for how long?
What specific fitness or health goals do you hope to achieve through the Pilates method?

Stress reductionRehabilitationStrengthen MusclesImprove mobilityImprove the mind/body connectionMedical Reason? Please describe belowOther
Feel free to elaborate on any of your goals
Do you exercise or participate in any physical activities or sports? if so, what kind and how often?
Have you had any recent surgeries, broken bones, major accidents etc? if yes, please explain:
Do you suffer from any health conditions that we should be aware of before giving you a session?

Please specify which areas of your body are presently or in the past have been injured. Please mark Right (R) or Left (L) if it applies. If none leave blank

	Yes	Right	Left
Head
Neck
Shoulders
Elbow
Wrist/Hand
Upper back
Mid Back
Lower Back
Abdomen
Pelvic Floor
Hip
Knee
Ankle/Foot

Do you have or have you ever had ANY of the following? If none leave blank

	Yes
Arthritis or Joint Disorders
Asthma
Coronary heart disease or Angina
High Blood Pressure
Have a pacemaker
Heart attack
Stroke
Blood clot
Epilelsy/Seizures
Thyroid/Goiters
Anemia/Fainting Spells
Diabetes
Cancer
Osteoporosis
Sleeping problems
Cancer
Infections diseases
Gout
Migraines
Vision or hearing difficulties
Numbness or tingling
Hernia
Varicose veins
Allergies
Joint replacements
Autoimmune disease
Joint Replacements
Pins or metal implants
Pelvic Pain
Incontinence

Feel free to elaborate on any of the above or other conditions:
How did you find out about me?
POLICIES

1. All private sessions are 55 minutes

2. Please silence all cellphones when entering the home studio. Please mute yourself at the beginning of group virtual sessions.

3. The session begins at the appointment time. Not at the time of arrival.

4. It is requested that you not handle any equipment or exercise in the home studio without the presence or following the direction of a teacher.

5. Pilates socks are required for all sessions.

6. Packages are non-refundable. Must be used within 90 days.

Covid-19 POLICIES

Mask wearing is mandatory

Proof of vaccination is required

Please refrain from coming to class if you are experiencing any of the following symptoms: fever, cough, shortness of breathe of difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste of smell, sore throat, congestion or runny nose, nausea, diarrhea.

If you have a known close positive Covid-19 case requiring your family to quarantine and do any testing, please immediately notify Nicole via phone or email.
Upload proof of Covid Vaccination Record

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RELEASE OF LIABILITY

1. I do hereby forever waive, release and discharge Nicole Bennett (also referred as Culver City Youth Ballet LLC) and its officers,agents, employees, representatives, executors and all others acting on their behalf from any and all claims or liabilities for injuries or damages to my person and/or property, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf, arising out of or connected with my participation in any activities, programs or services of Nicole Bennett (also referred as Culver City Youth Ballet LLC) or the use of any equipment at various sites, including home, provided by and/or recommended by Nicole Bennett (also referred as Culver City Youth Ballet LLC).
2. I have been informed of, understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also have been informed of, understand and am aware that fitness activities involve a risk of injury, including a remote risk of death or serious disability, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death.
3. I understand my physical limitations and am sufficiently self-aware to stop physical activity before I become ill or injured or have a change in health that would be pertinent to my work with Nicole Bennett (also referred to as Culver City Youth Ballet LLC) such as but not limited to: pregnancy, temporary or permanent change in health or changes in medication that may affect how the body responds to exercise.
4. I understand and declare that I have disclosed all injuries, both past and present and preexisting conditions, on my intake form and keep an ongoing conversation with Nicole Bennett of all injury
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