Rise & Grind Pilates New Client Registration Form

RISE & GRIND PILATES

13 Holmeswood Court, Para Hills West 5096 SA

risengrindpilates@gmail.com

www.risengrindpilates.com.au

0493100527
Customer Details:
Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
E.g 23
Gender

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Emergency Contact Person

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.
How did you hear about us?*
Health History
Do you currently exercise / have you previously exercised before?

YesNo
If yes, please write a brief summary of what exercises you have participated in I.e how many days a week / classes / what exercise do you LOVE / etc
Are you currently pregnant

YesNo
If yes, how many weeks along are you & how is your pregnancy going so far? Is this your first pregnancy?
Do you have any allergies?

YesNo
Please list any medications you are taking
Do you have any cardiovascular disease?

YesNo
Do you have any respiratory disease?

YesNo
Do you have asthma

YesNo
Have you recently undergone surgery? If yes, please list what the surgery was for & when this occurred.
Do you have any medical condition that you would like to share? This includes injuries, car accidents, prolapse, depression / anxiety, etc.
Goal Setting

We set goals to give your training purpose & direction. Your goals matter to us because we want your time to be intentional & we want to help you achieve any goal, big or small, mental or physical. Please think carefully about your answers to these as it will dictate how we plan your sessions & how you show up for yourself each time!
Wellness goals
Fitness Goals
Why is it important to you to make these changes and/or dedicate this time for yourself?
Consent Agreement
I, The client, fully understand that physical program, exercise can lead to injury and that I take responisbilty to injuries. I am physically safe to exercise and there is no medical concern that I have not spoken to my instructor about

I consent that I have read and fully understand the above and everything is answered truthfully, am over eighteen years of age and am legally liable for my own decisions/actions.

By signing below, it means that I agreed to the terms indicated in this document.
Date Signed

MonthDayYear
Date
Client Signature*

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Customer Details:

Health History

Goal Setting

Consent Agreement