Soul Movement – Online Studio Waiver & Induction Form

Personal Information
Full Name*
Date of Birth*

DayMonthYear
Date
Gender*
Address*
City*
Phone Number*
Email Address*
Emergency Contact
Full Name*
Relationship to You*
Phone Number*
Medical Provider *
Safety Induction Checklist
I confirm I have:*

Viewed the Soul Flex Induction videoViewed the Soul Fire & Ice Induction video (if applicable)Been shown the first aid kit location on the right in the kitchenBeen shown the two fire exits, located at the main entrance & beside the toiletBeen shown the location of the incident report and will report any hazards or injuries to Anna
Health Information
Medical Conditions (tick any / all that apply):
Cardiovascular & Pulmonary

Diagnosed heart condition or strokeUnreasonable leg/chest pain during exerciseDiagnosed pulmonary disease
If ticked, you must only proceed with medical clearance
Risk Factors

Family history of heart disease/stroke (under 55/65)High blood pressure (over 140/90)Asthma (attack requiring medical attention in last 12 months)Smoker or recently quit (within 6 months)Bone or joint problemsAny condition increasing risk of exercisePregnant (now or in past 12 months)EpilepsyArthritis
Musculoskeletal Concerns

Feet/AnklesKneesHips/GroinLower BackUpper BackNeck/ShouldersArms/ElbowsWrists/HandsHamstrings
Pelvic Health

Diagnosed prolapsePelvic painIncontinencePain during intercourseHistory of pelvic surgery or trauma
Have you given birth? If yes, how many times
Please explain any ticked items, surgeries, medications, or physical limitations:
Fire & Ice (Contrast Therapy) – If applicable
Contraindications – Please tick if any apply:

Cardiovascular disease or uncontrolled blood pressurePregnancy (Fire & Ice is not for use when pregnant under any circumstances)Open wounds, recent surgery, or skin sensitivitySeizures or epilepsyRaynaud’s diseaseCold urticariaRecent illness or fever
If any apply, consult a medical professional before proceeding.
I acknowledge I’ve been instructed on safe entry/exit, time limits, and temperature exposure for the sauna and ice bath.

Yes
I agree to stay hydrated and listen to my body throughout the session.

Yes
Studio participation
Please confirm:

I will complete the Soul Beginner series as my first classesI understand studio hours (5:30am–9:30pm)I will clean equipment after use using cloths or wipes and leave it tidyI understand I can pause/cancel membership via email (5 working days notice)
Pilates Experience:

BeginnerIntermediateAdvanced
What are your movement goals?
Informed Consent & Waiver
I confirm*

All information provided is accurateI take full responsibility for my health during participationI release Soul Movement and its staff from liability for any injuries or incidentsI understand that any physical activity or therapy carries inherent risk
Full Name*
Signature*

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Todays Date*

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Should be Empty:

Personal Information

Emergency Contact

Safety Induction Checklist

Health Information

Medical Conditions (tick any / all that apply):

Fire & Ice (Contrast Therapy) – If applicable

Studio participation

Informed Consent & Waiver