Exercise Class Participant Questionnaire

Client Information

For participation in Rebel Flow Pilates classes
Full name

First NameLast Name
Birth Date

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Phone Number

Area CodePhone Number
Emergency Contact Name

First NameLast Name
Emergency Contact Phone number
Format: (000) 000-0000.
Health questionnaire (Par-Q)
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

PAR-Q

Rows	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for blood pressure or heart condition?
In the past 12 months have you had any major illness or surgery?
Do you know of any other reason why you should not do physical activity?

If you have answered YES to any of the PAR-Q sections then you are required to gain consent from your doctor before participating in the exercise programme.

An exercise programme will include exercises designed around your needs and goals. The programme will work all components of physical fitness and use the principles of training.

You are advised to postpone entry into the programme if you feel unwell or have a temporary illness.

You must inform your instructor of any changes to your health status whilst engaged in your training programme.

Pregnant and post-natal clients

Rows	Yes	No
Are you pregnant or have given birth in the past 6 months?

The instructor for this class is not qualified in pre or post-natal Pilates. In order to keep you and your baby safe, unfortunately we cannot continue with the class at this time. If you have already paid, a full refund will be offered and we can help sign-post you to alternative practitioners. We really hope to welcome you on the mat in the future. Thank you for your understanding.
Is there anything else you'd like the instructor to be aware of? (e.g. low back pain, tight hamstrings, etc.)
I have read, understood and completed this questionnaire to the best of my knowledge.
Initials
Acknowledgement of Risk and Responsibility
I understand that participation in Pilates involves physical activity and that, as with any exercise, there are inherent risks including, but not limited to, muscle soreness, strains, joint or soft tissue injury, dizziness, or aggravation of pre-existing conditions.

I acknowledge that it is my responsibility to follow the instructor’s guidance, exercise within my own limits, and immediately inform the instructor of any pain, discomfort, or health changes.

I understand that the instructor will take reasonable care to provide safe instruction and guidance, but it is not possible to eliminate all risk or predict individual responses to exercise.

I confirm that I am voluntarily participating and accept the inherent risks associated with Pilates.

Nothing in this declaration excludes or limits liability for death or personal injury caused by negligence, or any other liability which cannot be excluded under Northern Ireland law.
Initials
Cancellation Policy
For single booking classes, cancellations must be received at least 12 hours before your class or training session to enable you to rebook for a later date. Clients who do not cancel with 12 hours' notice will be unable to rebook and will lose the fee for that session/class.

Refunds are not given for block booking or drop-ins.
Initials
Date

JourMoisAnnée
2 digit day, 2 digit month, 4 digit year

Informed Consent

For participation in Rebel Flow Pilates classes
To be read alongside your completed PAR-Q and health questionnaire

Consent to Participate
I confirm that I voluntarily wish to participate in Pilates sessions, which may be delivered in a group or one-to-one setting.

I understand that Pilates is a form of physical exercise designed to improve strength, posture, flexibility, balance, and overall wellbeing. In group sessions, exercises may not always be individually tailored.

Risks of Participation
I understand that all physical activity carries some risk, including but not limited to:

- Muscle soreness, fatigue, or strain
- Joint discomfort or aggravation of existing conditions
- Loss of balance, slips, trips, or falls
- Temporary changes in heart rate, breathing, or blood pressure

I understand that it is not possible to eliminate all risks associated with exercise and that individual responses to physical activity cannot be predicted with complete accuracy.

My Responsibilities

I confirm that:

- The information provided in my PAR-Q and health questionnaire is accurate and complete
- I will inform the instructor of any changes to my health or medical condition
- I will work within my own ability and comfort level
- I will follow instructions and notify the instructor if I experience pain, dizziness, or discomfort
- I may stop participation at any time

Benefits of Pilates
I understand that regular participation may help improve:

- Strength and core stability
- Flexibility and mobility
- Posture and balance
- General fitness and wellbeing
- No specific results or outcomes are guaranteed.

Consent Statement
I confirm that:

- I have read and understood this form
- I have had the opportunity to ask questions, and they have been answered
- I understand the nature of Pilates and the associated risks and benefits
- I voluntarily agree to participate

Data Protection (UK GDPR / Northern Ireland Law)
I understand that my personal and health information will be collected, stored, and processed in accordance with UK General Data Protection Regulation (UK GDPR) and applicable Northern Ireland data protection legislation, and will be used only for the safe delivery of Pilates instruction.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Signature
Should be Empty:

Client Information

Health questionnaire (Par-Q)

Acknowledgement of Risk and Responsibility

Cancellation Policy

Informed Consent