Querencia Pilates Intake Form

Today's Date

Date

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Phone #

Area CodePhone Number

Date of Birth

MonthDayYear

Email

example@example.com

Are you currently physically active? If yes, what sort of activities do you participate in?

What are your fitness or health goals that you would like Pilates to help you achieve?

Do you have ANY injuries or health conditions? If so please list. (For example: osteoporosis, pregnancy, joint pain, surgeries, scoliosis, asthma, high or low blood pressure, etc.)

Have you ever participated in Pilates before? If yes, please describe prior experience:

Are you comfortable with manual feedback (touch)?

I understand Querencia Pilates enforces a 24 hour cancellation policy and that if I don't cancel my scheduled appointment 24 hours in advance I will be charged in full.

I understand any packages purchased at Querencia Pilates expire within 6 months, are non-refundable and non-transferable.

Waiver of Liability and Informed Consent Release of Querencia Pilates, LLC

I have enrolled in a program of instruction in the Pilates Method of physical conditioning offered by Querencia Pilates. I have been advised and I understand that participation in Pilates Method exercise and conditioning activities, like any physcial conditioning activity or exercise program, 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 results of these exercise lessons, including possible short-term aggravation of some symptoms, feelings of tiredness, light-headedness, increased energy, mood changes, etc.

I also understand that a medical evaluation is advised before commencing any program of physical conditioning exercise. I have and will continue to keep Querencia Pilates and my instructor fully informed of any physical condition or disability, which would prevent or limit my participation in an exercise or physical conditioning program. I acknowledge that, although the conditioning program I participate in may have substanital physical benefits, neither Querencia Pilates nor the instructors within are engaged in diagnosing or treating medical diseases or deficiencies.

I assume all risks of my participation in the programs of the Pilates Method conditioning program conducted by Querencia Pilates and waive any claim with I might otherwise bring against Querencia Pilates as a result of injuries resulting from or relating to my participation in Pilates Method conditioning programs.

Querencia Pilates shall not be responsible or reliable for any articles lost, stolen, or damaged, in or about the studio.

I understand that Pilates lessons require prior evaluation of my fitness level and that I am responsible for attending the appropriate level class.

I acknowledge I am relieving Querencia Pilates of any and all liability for injuries, damages, or losses to myself, the undersigned, other persons or Querencia Pilates. I have read this agreement thoroughly and understand the terms. No oral representations or statements or inducements have been made to me that change, alter, or modify anything within this written agreement.

I agree to the above terms & conditions.

Signature

Intake Form & Waiver