Welcome! Please complete this form before your first session. Your information helps me provide safe, personalized Pilates and wellness guidance.

I understand that I am participating in Pilates-based movement sessions and wellness services provided by Mira Movement. These services may include, but are not limited to: 

Private 1:1 Pilates sessions  
Duet Pilates sessions 
Individualized exercise programming  
Postural and movement analysis 

 

I understand that all clients begin with an introductory session, which includes a comprehensive postural and movement assessment to guide individualized programming. 

I acknowledge that Mira Movement operates as a wellness and fitness service and is not a medical or physical therapy provider. 

I understand that participation in physical activity involves inherent risks, including but not limited to

Muscle soreness
Joint irritation
Risk of Falls or injury
Aggravation of existing conditions

I knowingly and voluntarily assume all risks associated with participation in these services. 

I understand that participation in physical activity involves inherent risks, including but not limited to

Muscle soreness
Joint irritation
Risk of Falls or injury
Aggravation of existing conditions

I knowingly and voluntarily assume all risks associated with participation in these services. 

I hereby release, waive, and discharge Mira Movement  from any and all liability, claims, demands, or causes of action arising out of or related to any injury, loss, or damage that may occur as a result of my participation. 

This release applies to all sessions, including private, duet, and any future services provided. 

I understand that: 

My sessions are tailored to my individual needs based on my assessment 
No guarantees are made regarding outcomes or results 
I may stop any exercise at any time 
I voluntarily consent to participate in Mira Movement services. 

I understand that: 

All sessions are by appointment only  and are 50 minutes long
No self-scheduling is permitted 
Packages (5-session and 10-session) must be paid in full prior to use 
Pay-as-you-go sessions are due at the time of service  
No payment plans are offered 

I acknowledge that scheduling and payment are managed through Square. 

I understand that: 

A minimum of 24 hours' notice is required to cancel or reschedule   

A $50 cancellation fee will be charged for late cancellations or missed sessions

I understand that: 

Each participant must complete an individual introductory session prior to participating in duet 
sessions 

Duet sessions involve shared instruction and individualized modifications 

I understand that: 

My personal and health information will be collected to provide safe and appropriate services 

Mira Movement is not a HIPAA-covered entity, but reasonable measures will be taken to maintain confidentiality and protect my information 

I understand that: 

Posture photos may be taken during my introductory session and at the end of a package to assess progress 

These photos are for internal use only unless I provide separate written consent for marketing purposes 

I understand that: 

Grip socks are required during sessions 

 

Barefoot Policy (Optional Addition)

I understand that grip socks are recommended for safety during Pilates sessions. I may choose to participate barefoot; however, I acknowledge that doing so may increase the risk of slipping or injury.

By choosing to be barefoot, I voluntarily assume all associated risks and release Mira Movement  from any liability related to injuries that may occur as a result of this choice.

I have read, understood, and agree to all terms outlined in this waiver. 

I acknowledge that I am participating voluntarily and assume full responsibility for my participation.