Coastal Core Pilates - Client Registration and Waiver Form

Client Registration, Physical Activity Readiness Questionnaire (PARQ) and Safety Waiver Form

Please fill out the form below for your safety and wellbeing, prior to attending mat / chair / reformer Pilates. Please contact Emily with any queries (emily@coastalcorepilates.org) Thank you!
Client Registration

Welcome to Coastal Core Pilates and we are excited to start moving together! Thank you for providing the following information.
Full Name*

First NameLast Name
Email Address*
example@example.com
Mobile Phone Number*
Please enter a valid phone number.Format: (00000000000).
Date of Birth*

DayMonthYear
Date
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (00000000000).
I would like to register to attend / register my interest in the following mat, chair or reformer Pilates classes with Coastal Core Pilates:*

Mat Pilates: 18:00 Thursday @ St Martin-in-Meneage Village HallChair Pilates: 13:30 Wednesday @ Cury Recreation HallI am interested in upcoming Mat Pilates classes in Constantine, Falmouth and would like to be updated.I am interested in upcoming one-to-one Reformer Pilates classes in Constantine, Falmouth and would like to be updated.
Do you have previous experience with Pilates (Mat / Chair / Reformer)?*
Yes / No and please give brief details - thank you!
What are your goals or intentions for practicing Pilates?
Physical Activity Readiness Questionnaire

A Physical Activity Readiness Questionnaire (PARQ) form needs to be completed by all participants prior to commencing mat, chair or reformer Pilates with Coastal Core Pilates. This is an industry-standard requirement for participants aged 15-69 in group fitness and ensures that you can exercise safely. If you are over 69 and not previously active or have significant health issues (if YES to any of the multiple choice questions) then medical clearance to exercise may be indicated and please contact Emily to discuss. PARQ form to be updated every 6-12 months or with any significant change in physical health. Personal information will remain confidential and securely stored as per GDPR.
Please select the relevant option:*

I am 18yrs or over, am completing this PARQ form on behalf of myself and have capacity to do so.I am completing this PARQ form as a parent / legal guardian of the participant as they are under 18yrs of age.
Please complete as indicated:*

Heart disease / cardiovascular diseaseDiabetes - Type 1Diabetes - Type 2CancerBone / Joint ConditionCOPD / AsthmaDementiaEpilepsyNeurological conditionNone of the above medical conditionsOther
If indicated - please provide further details on your health condition and management plan - does it affect your ability to perform physical activity and if so how? *
If no response required please write N/A.
Do you have any acute or chronic injuries, that required medical / surgical / physiotherapy input? Do you have ongoing pain / weakness / altered sensation / joint stiffness?*
Please type YES / NO and give details if YES.
Do you have a heart condition and should only do physical activity that is recommended by a doctor?*

YesNo
Do you ever feel pain in your chest during physical activity or exertion?*

YesNo
Do you ever feel pain in your chest when not doing physical activity / during rest?*

YesNo
Do you ever get dizzy, causing you to lose your balance or to lose consciousness?*

YesNo
Do you have a joint or bone problem that may be made worse by a change in your physical activity?*

YesNo
Are you currently prescribed medication for your blood pressure or heart condition?*

YesNo
Are you pregnant or recent post-partum? If so then please contact Emily to discuss safe exercise options for Pilates.*

Yes - PregnantYes - Post-partum (<12m)No
Do you know of any other reason that you should not exercise or increase your physical activity?*

YesNo
Please give further details if answered YES to the question above.*
Please write N/A if no response needed.
Having answered YES to one or more questions above, I have sought medical advice and my health care professional has agreed that I can attend Pilates classes for exercise - please contact Emily to discuss as needed. If answered NO to all questions, then I agree that I am safe to attend classes with Coastal Core Pilates.*

I agree.
In respect of the Data Protection Act 2018, I understand that this information I have shared will be used for the sole purpose of my participation in Coastal Core Pilates activities. It will be treated confidentially and stored securely.*

I agree.
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in a suitable level of physical activity and exercise and I am responsible for managing my participation level and risk.*

I agree.
I agree it is my responsibility to update Coastal Core Pilates staff with any relevant changes to my health information that might impact me taking part in physical activity.*

I agree.
Waiver

Safety Liability Waiver and Signature of Agreement
I, the undersigned, hereby acknowledge and understand that participation in mat, chair and reformer Pilates classes and related activities conducted by Coastal Core Pilates involves certain risks and potential dangers. By signing this waiver, I voluntarily agree to participate in the class and assume all risks associated with my participation.*

I agree.
I acknowledge that I am voluntarily participating in the mat, chair and reformer Pilates class(es) provided by Coastal Core Pilates. I understand that physical exercise, by its very nature, carries with it certain inherent risks of physical injury (such as but not limited to strain, sprain, fracture) or discomfort, and even the possibility of serious injury or death. I hereby assume all risks and responsibility for any such injuries or other medical incidents.*

I agree.
I represent that I am physically fit to participate in the mat, chair and reformer Pilates class(es) and have no medical condition that would prevent my safe participation. If I have any medical conditions or concerns, I have consulted with a healthcare provider and obtained clearance to participate. I consent to honest and accurate completion of the PARQ form prior to participation in Pilates classes.*

I agree.
I hereby consent to receive any necessary medical or physiotherapy review and / or treatment resulting from my participation in the mat, chair and reformer Pilates class(es) and agree to bear all costs associated with such. I am aware that there is no obligation for any person or staff to provide me with medical care during the activity, other than emergency first aid as per staff certification and insurance.*

I agree.
I agree to release and discharge Coastal Core Pilates, the venue and/or the instructor from any and all liability, claim, demand or action that I may have relating to the loss, theft, or damage to any of my personal property during a Pilates session.*

I agree
I confirm that I am over 18 years of age and have capacity to agree to this waiver; or I am the parent / guardian of a participant under the age of 18 and with my signature I give full consent to this waiver. Clients 16years and under must be accompanied to class by a responsible adult with signed permission of their parent / legal guardian*

I confirm that I am 18yrs or over and have capacity to agree to this waiver.Parent/Guardian Signature (if registering client is under 18yrs). Participants 16yrs or under must be accompanied to class by a responsible adult.
I have read this waiver, understand its contents, and agree to its terms. I confirm that the information I have provided is accurate at the time of submitting this form and that I will update Coastal Core Pilates with any relevant changes in a timely way. I recognise that this Agreement of Release and Waiver of Liability is a legal contract and that, by reading it carefully, I have complete knowledge of its contents. If any provision of this Agreement shall be unlawful, void or for any reason unenforceable, then that provision shall be deemed severable from this agreement and shall not affect the validity and enforceability of any remaining provisions. I understand that I am giving up substantial legal rights by signing it.*

I agree.
Signature*
Date*

DayMonthYear
Date
Thank you for completing this form! Your responses will be sent to you in an email, if you consent to receive this as per GDPR.*

Yes, I’m happy for a copy of my responses to be emailed to me.No thanks.
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Client Registration, Physical Activity Readiness Questionnaire (PARQ) and Safety Waiver Form

Client Registration

Physical Activity Readiness Questionnaire

Waiver