Client Profile Form

Client Profile & Release Form
Full Name*

First NameLast Name
E-mail*
example@example.com
Date Of Birth*

MonthDayYear
Date
Cell Phone Number*
Home Phone
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Cell Phone Number*
Please enter a valid phone number.
Preferred Contact Method
Previous Pilates Experience*
Describe any pertinent medical conditions i.e.high or low blood pressure, chronic fatigue, autoimmune disease, etc. *
Describe any injuries past or present
Describe your main goals that you hope to attain from Pilates*
How did you hear about Grass Roots Pilates? *
Please Specify*
Check the type of programs you are interested in.*

PrivatesDuetsSemi PrivatesGroup ClassesIntro to Group Classes4-6 Week Specialized WorkshopMaster ClassesMat Classes
Do you have any special requests?
I, {fullName3} hereby acknowledge that I have voluntarily applied to enroll in a program of instruction based on the Pilates Method of physical conditioning offered by Grass Roots Pilates LLC. I am aware and understand that the Pilates based method involves strenuous physical activity including muscular strength building, flexibility and stretching, endurance and the use of exercise equipment. I have been advised and understand that participating in the Pilates based method, like any physical conditioning activity of exercise program, presents some risk of injury for all participants and especially to people who have preexisting injuries, certain medical conditions, and physical and/or mental disabilities.
I am voluntarily participating in these activities with the knowledge of the risks involved and hereby agree to accept any and all risks of injury or death.
Initial*
As lawful consideration for being permitted to participate in the Pilates based method of physical conditioning offered by Grass Roots Pilates LLC and utilizing the facilities of Grass Roots Pilates LLC, I hereby release for myself, my spouse, legal representative, heirs and assigns (“Releasing Parties”) and waive and discharge Grass Roots Pilates LLC, and its owners, agents, representatives and employees (“Released Parties”) from any and all liability to the Releasing Parties for any and all losses, liability, claims, causes of action, damages or costs arising with respect to any bodily injury, personal injury, illness, death, property damage or other harm, whether caused wholly or in part by the negligence, fault or other conduct of any of the Released Parties, or otherwise, arising from or in any way related to my presence on or about the premises of the Grass Roots Pilates LLC studio, whether engaged in physical activity or otherwise, or my participation in the activities described herein (“Claims”). I further specifically agree to indemnity Nicole Comella, Manager, from any and all such Claims.

I understand and agreement that any expense directly or indirectly related to any accident, injury, or illness incurred by me as a result of my participation in the activities described herein will be my sole responsibility, and that the Released Parties will bear no responsibility for my medical issues or medical costs.

This waiver and indemnity is intended to be as broad and inclusive as permitted by the laws of the State of California and that if any portion of this Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I hereby acknowledge that I have carefully read and voluntarily sign this Release and Waiver of Liability and Indemnity Agreement. I further acknowledge that no oral representations, statements, or inducements apart from the foregoing written agreement have been made.
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Form Submission Date*

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Client Profile & Release Form