General Registration Form

Name*

First NameLast Name

Date of Birth*

DayMonthYear

Address*

Street Address

Street Address Line 2

City

Zip Code

Contact Phone Number*

Area CodePhone Number

E-Mail*

Do you suffer from any of the following health conditions

	Yes	No
Heart disease
High blood pressure
Low Blood pressure
Other cardiovascular problems
Arthritis (rhumatoid or osteo)
Allergies/asthma/other respiratory conditions
Chest pain
Fainting or dizziness
If yes, is it made worse by exercise
Do you ever lose consciousness or fall over as a result of dizziness

Please give details for any 'yes' answers:

Other medical queries

	Yes	No
Have you had any surgery, recently or otherwise?
Are you taking any medication at the moment?
Are you currently experiencing any pain?
Are you currently under the care of a doctor, physio, osteopath or other healthcare professional?
If so, have you informed them you are starting Pilates classes?
Do you have any other condition that may affect your ability to exercise safely?
If you have answered yes to any of the following questions, do you feel the issue could be aggravated by Pilates classes?

Please give details for any 'yes' answers

Do you have any past medical history or problems?*

The classes provided by Centred Mums are for educational purposes only, and are not be interpreted as a recommendation for a specific treatment plan or course of action.

Exercise is not without risks and this or any other exercise programme may result in injury. They include but are not limited to: risk of injury, aggravation of a pre-existing condition, or adverse effect of over-exertion such as muscle strain, abnormal blood pressure, fainting, disorders of heart beat, and very rare instances of heart attack. To reduce the risk of injury, before beginning this or any exercise programme, please consult a healthcare provider for appropriate exercise prescription and safety precautions. The exercise instruction and advice presented in the classes are in no way intended as a substitute for medical consultation. Centred Mums disclaims any liability from and in connection with the classes.

As with any exercise programme, if at any point during the exercise videos you begin to feel faint, dizzy or have any physical discomfort, you should stop immediately and seek medical advice.

Please take note of the following precautions before taking the class:

To reduce and avoid injury, you will want to check with your doctor before beginning the exercises included in the course. By participating in the classes you are doing so at your own risk. Centred Mums will not be responsible or liable for any injury or harm you sustain as a result of our Pilates programmes.

Please use good judgement and common sense when taking the class, consider your stage postnatally, level and ability and choose the appropriate level of the exercises and rest when you need to.

Please ensure you are in a clear space with no obvious hazards, with ventilation, appropriate lighting and access to water.

Completing this form, you confirm to abide by the terms of this disclaimer.

I have read and understood this declaration

Yes

I agree to the Centred Mums T&Cs which can be found at the following linkhttps://centredmums.com/terms-and-conditions/

Yes

I consent to my details being stored by Centred Mums and agree to the Data Protection Policy which can be found at the following link https://centredmums.com/data-protection-policy/. I am aware that my data will be safely stored for the next 7 years as Centred Mums is legally obliged to do so for insurance purposes. I understand that any information I have given is used exclusively by Centred Mums and will not be shared with anybody else. I understand I cannot join the classes without giving this consent as it would mean Centred Mums would not be insured to teach me.

Yes

Would you like to be added to the Centred Mums mailing list? We will only contact you regarding classes that may be of interest and will not give anyone else your contact details.

YesNo

Client Signature*

By signing you agree to the conditions stated above

Centred Mums Basic Registration

Program Information