RYC Liability Waiver

Intake Form

Movement Services
Client Information Questionnaire
All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to developing a program that addresses your needs, goals, and interests and is safe and effective.

Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Occupation:
Emergency Contact:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Physician's Name:
Physician's Phone:
Physician's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please provide 24 hours notice if you need to cancel or reschedule your appointment.
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?
Do you frequently have pains in your chest when you perform physical activity?
Have you had chest pain when you were not doing physical activity?
Do you lose your balance due to dizziness or do you ever lose consciousness?
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?
Are you pregnant now or have given birth within the last 6 months?
Have you had a recent surgery?
Please check all conditions you have encountered throughout your lifetime.
Head/Neck

Other
Shoulders

Other
Arm/Hand

Other
Spine/Upper Or Lower Back

Other
Leg/Knee

Other
Foot/Ankle

Other
Neurological/Limbic

Other
Digestive

Other
Respiratory

Other
Cardiovascular

Other
Lymphatic

Other
Organ Functions

Other
Reproductive/Urologic

Other
Hips/Pelvis

Other
Please include information on ANY surgeries (cosmetic, outpatient, injury repair, reconstructive, laparoscopic, etc.), injuries, pregnancies, deliveries, cesareans, etc.
Do you take any medications, either prescription or non-prescription, on a regular basis?
If yes, what is the medication for and how does it affect your ability to exercise?

Please indicate your top 3 goals for your exercise session.

Rows	Goals
1
2
3

Please use this section to describe why you are seeking help from Yoga Heart & Mind LLC / Stephanie Watson Lewis. Include any relevant history or pain, discomfort, surgery and injury. Please also mention any stresses in your life which are above your usual. Please also include any emotional difficulties or anything in your whole body – physical, emotional, social that are of significance.

I, Client Name*, wish to participate in the exercise and training program offered by Stephanie Watson Lewis I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. I agree that Stephanie Watson Lewis shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge Stephanie Watson Lewis from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.

I agree not to hold Yoga Heart & Mind LLC/Stephanie Watson Lewis, or any of its affiliates liable for any injury or damages related to my participation in 1-on-1 sessions, in person classes, online classes, workshops, trainings, retreats or other activities.
I have read and understand this term.
I certify that the answers to the questions outlined on the PAR-Q form are true and complete to the best of my knowledge. I acknowledge that medical clearance is required if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform the instructor of any conditions or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury.
I understand that I am not obligated to perform nor participate in any activity that I do not wish todo, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform the instructor.
I understand the results of any exercise program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.
I understand that all private session rates are based on 30 or 50 minute sessions and should I arrive late, there is no guarantee I will receive the full session with the instructor. In return, if the instructor is late for a session, I will still receive the full session time.
I understand that Yoga Heart & Mind LLC / Stephanie Watson Lewis operates on a scheduled appointment basis for all personal sessions and thus, requires that I provide 24 hours notice when canceling an appointment. No charge will be levied should I cancel with MORE than 24 hours notice given.
I understand that during an exercise session, Yoga Heart & Mind / Stephanie Watson Lewis may have to use Touch Training to correct alignment and/or to focus my concentration on a particular muscle area to be targeted. If I feel uncomfortable or experience any type of discomfort with Touch Training, I will immediately request that the instructor discontinue using this technique.
I understand that Yoga Heart & Mind / Stephanie Watson Lewis photographs many of her client events/sessions and I provide written approval for her to use these pictures for promotional purposes.
I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.
Signature:
Today's Date:

MonthDayYear
Date
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