Coco Pilates Client Registration Form

Customer Details:
Full Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Occupation:*
Sport/ Hobbies:*
Please select the Studio you would like to attend*

Coco Pilates SandtonCoco Pilates Steyn City
How did you hear about the studio?*
Are you a Discovery Health Vitality Member?

YesNo
If yes, would you like to earn Vitality points for classes?

YesNo
Please provide your ID number
Emergency Contact details:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relation:
Your Background & Health

Below information is shared in confidence with Coco Pilates. This information will not be shared or discussed with anyone without your concent.
Does your work & sport involve any of the following?

Sitting for long periodsDrivingBendingStandingLifting heavy weightsAny other repetitive actions
Will this be the first time that you have practiced Pilates?

YesNo
If you have practiced pilates please advise where

Pilates StudioPhysiotherapist practiceGymAt homeOther
Approximately how many classes have you attended?

0-55-1010-2020+
Has your doctor ever said that you have any sort of heart trouble or defect?

YesNo
Do you feel pain in your chest when you do physical activities?

YesNo
Are you, or could you be pregnant now?

YesNo
If yes, when is your due date?
Name & contact of Obstetrician/ Midwife
Have you been pregnant in the past 6 months?

YesNo
If yes how was your baby delivered?

VaginalCaesarean
Do you lose your balance because of dizziness or do you ever feel faint?

YesNo
Do you ever lose your consciousness from feeling faint or dizzy?

YesNo
Do you have high blood pressure?

YesNo
Have you had major surgery in the past 10 years?

YesNo
If yes, please tell us about the surgery and when it took place
Please select if you suffer from any of the below

AsthmaDiabetesEpilepsy
Have you ever been told that you have arthritic joint or bone problems

YesNo
If yes, please tell us more
Do you have pain or restricted movements in your joints?

YesNo
If yes, please tell us more
Have you been referred to Pilates by a special practitioner?

YesNo
If yes please select by who?

GPPhysiotherapistOsteopathChiropractorOther
Do you herby give permission for us to contact them?

YesNo

Please provide Practitioners contact information

	Practice Name	Contact Person	Contact Number
1
2
3

Please list any health problems not already listed above that may affect your ability to exercise
If you have answered yes to any above, we advise that you consult with your medical practitioner before you start Pilates classes. Clearance from your practitioner to practice Pilates will be required. Please state below if your practitioner have cleared you for physical exercise
Your Goals
What are your reasons for taking up Pilates?
What health or physical goals would you like to achieve in the short term?
What longer term health or physical goals would you like to achieve?
Studio Etiquette
Pilates is a hands on method. Tactile feedback is an important part of the instructors assistance to receive the required outcome. If you feel uncomfortable with tactile cueing, please inform your instructor before or after the class.

Punctuality - The classes are carefully structured to maximize the benefit to your body. We do understand how hectic life gets, but have to ask you to rather not attend class if you will be entering late, trusting that you understand missing the first few minutes is disrespectful to your body, the teacher and the fellow participants.

Attire - Shorts, leggings, fitter top and t-shirts all work well as appropriate attire. It is a good idea to wear layers on cold days. We also request that you wear socks to each class, normal or sticky socks. If you do not have socks with you, you will be provided with a pair of sticky socks at R100 to be added to your account.

Shoes - Please note that the studio have a no shoes policy. We kindly ask that you remove your shoes befor entering the studio and leave them in the designated areas.

Jewelry - We kindly request that you remove all jewelry (except smart watches) before each class. This is to protect the equipment from any accidental damages.

Nails - Should you have long nails we kindly request that you take care when handling the equipment not to damage any of the materials.

Cell Phones - Please make sure that your cell phone is left on silent in the designa area. The answering of cell phones within the class environment is disturbing for both teachers and fellow clients.

Cleanliness - A towel is also required at every session. The cleanliness of the studio and equipment is a priority for us and we would be grateful if you would let us know if at any time we do not shape up. As a courtesy to fellow clients and to our teachers, we ask that all clients make personal hygiene, particular clean feet, a similar priority, and thank you for your understanding in this sensitive matter.

Changing Rooms & Facilities - Please treat the changing room and Spa facilities with respect. This is a shared environment.
I hereby certify that I have read, Understand and Accept Assumption of Risk, Waiver and Release of Liability, and Indemnity Agreement as well as Studio Etiquette as stated above.*

YesI would like to discuss
If you would like to discuss any of the terms above - Kindly state yes or no and send an email if you selected "I would like to discuss."
clarisa_coco@me.com
Cancellation Policy & Payment
Cancellation Policy:

COCO Pilates act on a 12 hour cancelation policy.

Clients that cancel before this period will be able to reschedule a class on the Bookamat platform, in any available time slots within a 3 month period.

Classes will not be substituted for the next months bookings if you are using the weekly booking type.

Classes rates are non-refundable.

You are welcome to use credits to book for a friend to join you for class, please arrange this with Coco Pilates.

Class cancelation within 12 hours before scheduled class time will be forfeited.

Payment:

All class payments are due upfront for monthly bookings, pack booking or drop in bookings.

Please be aware that you pay for a slot in the Pilates schedule. We ask that you respect the schedule, your teachers and fellow clients in regards to bookings & payments and managing your schedule.

If fees are not received timeously your slot will not be secure. If you made bookings, have not paid, have not cancelled your booking and did not arrive for class you will still be liable for payment. Payment for monthly bookings to be received by 1st of the month. Payment for casual or pack bookings to be received on the day when the booking is made. If you are unable to continue with lessons kindly give a month notice in advance.

Please refer to the Coco Pialtes information pack for more information on booking types and how to manage your bookings.

Payment options:

Eft - Banking details as per invoice.

Bookamat online payment - Please note that 5% admin fee is
charged to your account for paying via Bookamat.

Yoco payment - Please note that 5% admin fee is
charged to your account for paying via Yoco.

Cash - Only by prior arrangement. Coco Pilates is a cash free facility, we do not keep cash to give you the corresct change.
I hereby certify that I have read, understand and accept Studio Cancellation Policy & Payment procedure as stated above.*

YesI would like to discuss
ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT
DECLARATIONS: This Agreement is entered into between trainer Coco Creations PTY T/A Coco Pilates (“Trainer”) and the undersigned (“Client”). The provision of personal training services by Trainer to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.

ASSUMPTION OF RISK: You agree that if you engage in any physical exercise or activity, including personal training, or enter our premises or use any facility or equipment on our premises for any purpose, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by Trainer or otherwise, including injuries or damages arising out of the negligence of Trainer, whether active or passive, or any of Trainer’s affiliates, employees, agents, representatives, successors, and assigns. Your assumption of risk includes, but is not limited to, your use of any exercise equipment (mechanical or otherwise), or other areas, locker rooms, sidewalks, parking lots, stairs, pools, or other general areas of any facilities, or any equipment. You assume the risk of your participation in any activity, class, program, instruction, or event, including but not limited to weightlifting, walking, jogging, running, aerobic activities, aquatic activities, or any other sporting or recreational endeavor. You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Trainer or otherwise.

RELEASE: You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Trainer (and Trainer’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Trainer, whether active or passive, or any of Trainer’s affiliates, employees, agents, representatives, successors, and assigns. This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including personal training, (d) negligent hiring or retention of employees, and/or (e) slipping or tripping and falling while on any portion of a premises or while traveling to or from personal training, including injuries resulting from Trainer’s or anyone else’s negligent inspection or maintenance of the facility or premises.

INDEMNIFICATION: By execution of this agreement, you hereby agree to indemnify and hold harmless Trainer from any loss, liability, damage, or cost Trainer may incur due to the provision of personal training by Trainer to you. ACKNOWLEDGMENTS: You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. You acknowledge that Trainer offers a service to his/ her clients encompassing the entire recreational and/or fitness spectrum. Trainer is not in the business of selling weightlifting equipment, exercise equipment, or other such products to the public, and the use of such items is incidental to the service provided by Trainer. You acknowledge and agree that Trainer does not place such items into the stream of commerce. This release is not intended as an attempted release of claims of gross negligence or intentional acts.

You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement. You are aware and agree that by executing this waiver and release, you are giving up your right to bring a legal action or assert a claim against trainer for trainer’s negligence, or for any defective product used while receiving personal training from trainer. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.
I hereby certify that I have read, Understand and Accept Assumption of Risk, Waiver and Release of Liability, and Indemnity Agreement as stated above.*

YesI would like to discuss
If you would like to discuss any of above term kindly send a email to clarisa_coco@me.com
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Should be Empty:

Customer Details:

Emergency Contact details:

Your Background & Health

Your Goals

Studio Etiquette

Cancellation Policy & Payment

ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT