Client Profile Form

Glow and Flow, A Spring Wellness Day

Co-presented by Grass Roots Pilates

and Jennifer Christine Transformational Coaching
Location: 1509 Chapala Street Suite B, Home of Grass Roots Pilates

Saturday, May 3rd 10am-3:30pm
Investment & Payment Options

The cost to attend the Wellness Day event is $117. To reserve your spot, you may submit payment via:

Venmo: @jennifer-somerville-1
Credit Card: Payments can be made in person at the studio.

Your registration is confirmed upon receipt of payment. We look forward to sharing this transformative experience with you!
Full Name*

First NameLast Name
E-mail*
example@example.com
Cell Phone Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about the Retreat?*
Please Specify*
I, {fullName3} hereby acknowledge that my participation in the Wellness Day event is voluntary and indicates my acknowledgement and agreement with the following statements:

a) It is my responsibility to consult a physician before participating in the physical activity of the day which includes Pilates, Yoga, Joint Mobility.

b) I agree to hold Grass Roots Pilates LLC and Jennifer Christine Transformational Coaching, their employees, owners, agents, trainers and representatives harmless from any damage, whether tangible or intangible, that may happen to me while participating in the Retreat. This may include but not limited to muscle strain, sprain, spasms, raised blood pressure, or injury from any unintentional accident.

c) I agree that it is my responsibility to let the Organizers know if I find myself in any pain or discomfort, before, during or after the retreat.

d) I agree that any and all medical treatment is my responsibility and I hold the Organizers blameless from any fees or charges that I may incur.
Media Waiver

I acknowledge and agree that before and during the Wellness Day event, I may be photographed and appear in videos to be used by Grass Roots Pilates LLC and Jennifer Christine Transformational Coaching for future events and marketing purposes only. I give consent to the use of photos and video while knowing that my image may be revealed in said marketing including print, social media and websites.
Initials*
Cancellation & Refund Policy

I understand that if I need to cancel my registration for the Wellness Day event, I may receive a refund, minus a $40 processing fee, if my cancellation request is submitted on or before April 19, 2025. After this date, all registrations are considered final, and refunds will not be issued. I acknowledge that this policy allows for the necessary planning and preparation required to create a meaningful and seamless experience for all attendees.
Initials*
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Location: 1509 Chapala Street Suite B, Home of Grass Roots Pilates