PAR-Q Falconè Pilates

This form is a industry standard screening PAR-Q (Physical Activity Readiness Questionnaire). All participants are required to complete and submit this form before taking part in any professional exercise programme. The information you provide here will help to assist us in supporting you throughout your fitness journey, and to help keep you safe during your physical activities with us here at Falcone` Pilates. We thank you for your cooperation.
Please fill in the required fields below marked by a RED asterisk. All other fields are Optional. However, answering all questions will help us further give you the best possible personal service!
Falconé Pilates Registration
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState/ Province/ Country

Postal Code
Home*
Please enter your home phone number
Mobile *
Please enter your mobile number
Date of Birth*

DayMonthYear
Email*

Confirmation EmailPlease confirm your email address
Gender*

MaleFemale
Age*
years
Please provide the name of your next of kin *

First NameLast Name
Next of kin home*
Please enter your home phone number
Next of kin mobile *
Please enter your mobile number
Relationship*
What is the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)Non applicable
How often do you exercise?*

RarelyDaily2-3 times WeeklyNever
Please list any physical activities you take part in here:
Has anyone in your immediate family developed heart disease before the age of 60?*

YesNo
Do have have any of the follow complaints?*

Back painStiff joints/ joint painWeak core strengthLow energyHi levels of stressLow moodArthritisKnee painShoulder or neck painHip painHip ReplacementKnee or Hip replacementNone
If any, what additional therapies are being undertaken for the given health problem(s)/ injury?
Are you experiencing any stresses or motivational problems?*

YesNo
Is there any history of heart disease in your family?*

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo
If you answered YES to any of the questions above please give a further explanation here:
If you are on any important medication please list them here and the reason they have been prescribed.
Do you smoke?*

YesNoI used to smoke
Are you pregnant?*

YesNo
Have you ever experienced any of the following?*

Chest PainsHeart diseaseHigh Blood PressureStrokeAsthmaEpilepsy/ SeizuresDiabetesAnginaDizzy SpellsDifficulty BreathingBack ProblemsDepression or AnxietyArthritisOsteoporosisScoliosisHip PainHip ReplacementKnee ReplacementNoOther
IMPORTANT: If you have had a hip or knee replacement please be sure to tell us here when your surgery took place.
If there anything else you would like to add regarding your health, please add further details here.
What following goals would you most like to achieve?*

Improve overall health & well-beingImprove stamina and enduranceIncreased strengthFat lossDecreased stress levelsJoint StrengthBack strengthImprove flexibilityImprove balance/ coordination/ motor skillsImprove mood
Have you had any previous Pilates experience? I.E. attended classes regularly?*

YesNo
At what times during the day do you prefer to train?*

MorningMid-DayAfternoonEvening
How frequently do you like to workout?*
What are your expectations of me as your Pilates/ Fitness coach?*
Please tell us the service you are interested in below
Please select one. All classes run on a monthly subscription plan (non-refundable)*

Complete Pilates - Monday's 11.15 am at Natural Fitness & Therapies. Upfront Monthly payment plan - £10 per class (non-refundable)Total Body Pilates - Wednesday's 9.30 am at Natural Fitness & Therapies. Monthly payment plan - £10 per class (non-refundable).Both Total Body & Complete Pilates (Both at Natural Fitness & Therapies) = 2 classes per week. Monthly payment plan - £10 per each individual class (non-refundable).Virtual Stott Pilates (Thursday's 10 am class. Online only. Monthly payment plan - £11 per class (non-refundable).Private Coaching (55 minutes £55. Initial introductory session - £60 (1 hour 15 minutes). Includes a Complimentary Postural Assessment.Pilates with a Pal (Two-to-One - 1 hour £70). Includes a Complementary Postural Assessment & Free Consultation.
NEW CUSTOMERS: How did you here about us?*

Google SearchFacebookInstagramTwitterRecommendationBlogWebsiteFlyer/ LeafletWord of mouth
Please read the following thoroughly: To help us show new customers we are a genuine business, class photos are intermittently taken during class and may be published to our website, social media, or used for other promotional material. Do you consent for images and/or videos of you in a group setting to be used for marketing and/or promotional purposes? We use images only - no names will be used. PLEASE NOTE: Those opting out of this option will either have their image blurred, removed or you may politely be asked to move aside while shots are taken.*

YesNo
I declare that all of the information I have given above is correct and to the best of my knowledge. I have sought out medical advice where needed prior to starting my new fitness programme and will follow any necessary advice from my doctor. I understand that all my information will be kept confidential*

YesNo
Please read all of the information below carefully regarding our Business Policies

PRIVATE COACHING

Payments for Private coaching is non-refundable.

Cancellations for Private coaching. Notice should be given no later 24 hours in advance to the exact time of the scheduled session. When the appropriate notice is given your appointment will be rescheduled at no charge.

Full charge of the session is incurred when a class is cancelled within less than the requested 24-hour period.

Private coaching clients should give no later than 1 months’ notice should they intend to cease classes. At least 2 weeks’ notice should be given where possible for holidays.

Should your coach need to cancel a Private Session your coach will rearrange your appointment to a time that is convenient to both parties.

CLASS PAYMENTS/ CANCELLATIONS

All classes: Payments are non-refundable.

Should your coach need to cancel any group class payment for the class missed will be passed over to the next available class (or month).

LATE ARRIVALS

All Group Class

Participants will not be given entry to class upon late arrival. Due to our health and safety policy all members must complete a warm-up. As well as for your safety, and to avoid disruption to the class and your coach, we politely ask that you arrive 5-10 minutes before the class time stated through our advertising.

*Privates Coaching Sessions - Due to our tight teaching schedule, classes cannot be extended due to the lateness by the client. Therefore, please arrive 5-10 minutes earlier to the appointment time agreed.

ONLINE CLASSES

Online classes commence without delay and meeting will be locked from the start time as advertised. Therefore, we ask that you arrive in good time (5-10 minutes) to be ready for you class so as not to be disappointment.

Online meetings are locked at the class start time to comply with our Health & Safety Policy as well as an attempt to not cause disruption to other attendees.

We thank you for your cooperation.
Please read the following carefully and then sign below

DISCLAIMER/ WAIVER

General Statement: On & Offline Program Objectives and Procedures:

I fully understand that physical fitness through Pilates or any fitness training programme provided online, and in-person uses and includes exercises of the musculoskeletal system.

A cardiovascular exercise program may be needed alongside Pilates training to decrease body weight and to increase cardiovascular health in individuals desiring to lose body fat. Pilates and any fitness programme can include the use of weights, Arc Barrels, Flex-bands, Fitness Circle, Foam Rollers, Soft balls, Ab Pads & head pads to either support postural alignment or to provide resistance. Depending on the individual’s needs, exercises will be executed through a combination of chair, standing, and or lying supine/prone positions.

DESCRIPTION OF POTENTIAL RISKS

I understand that the reaction of the heart, lungs, and blood vessel system to exercise cannot always be predicted with accuracy.

I know there is a risk of certain abnormal changes occurring during or following exercises which may include abnormalities of blood pressure or heart attacks to any persons at any one time.

The lifting of weights and or other equipment while engaging in heavy body or advance Pilates calisthenics, strength conditioning or aerobics taught may lead to musculoskeletal strains, pain and injury if there is not an inadequate warm-up or gradual progression, and if these safety procedures are not followed appropriately, I put myself at risk.

I understand that my Pilates Professional trainer Miss Oriana Falcone` of Falcone` Pilates shall not be personally, nor professionally, held liable for any damages arising from my personal physical injuries or mental wellbeing sustained by me the client or class member prior, during or subsequently to any personal or group online training program.

I agree and fully understand the risks involved in performing a fitness programme online, and or in person and do not hold Miss Oriana Falcone or Falcone Pilates accountable for any damages, physical or otherwise.

I the client agree that use of any equipment during my online class or in person, either one-one or in a group Pilates training programme is used entirely at my own risk. I the client assumes full responsibility for any injuries or damages which may occur during training.

FALCONÉ PILATES PHOTO RELEASE FORM                                [Applies only if you have given your consent in this form]

I hereby grant the Oriana Falconé, owner of Falconé Pilates, permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.

I understand and agree that all photos and videos will become the property of Oriana Falconé of Falconé Pilates and will not be returned.

I hereby irrevocably authorize Oriana Falconé to edit, alter, copy, exhibit, publish, or distribute these photos or videos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge the Oriana Falconé, owner of Falconé Pilates, from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE OR ABOVE. I AM CONSENT AS EVIDENCED BY MY SIGNATURES BELOW THAT I ACCEPT THE ABOVE TERMS AND CONDITIONS.
I have read, fully understood, and agree to the above Terms and Conditions*

Yes
Signature*

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Falconé Pilates Registration

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