New Client Registration & Health Questionnaire

New Client Registration & Health Questionnaire

Please complete this form before your first session. Your responses will help me understand your goals, experience, and any health considerations so your session can be adapted appropriately. Your information will be treated confidentially and used only to manage and safely deliver your sessions.
Personal Details
Full Name

First NameLast Name
Email Address
example@example.com
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile/WhatsApp Number
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Session Preferences
Which service(s) are you interested in? (select all that apply)
Session Format
How would you like to attend?
Preferred In-Person Location
Approximate Group Size
*Yoga and Deep Stretching groups are limited to 10 participants to maintain personal attention and session quality. Larger groups may be considered for Sound Healing, subject to venue and setup.
*Sound Healing sessions are offered in person to provide the full acoustic and physical experience of the instruments. If Sound Healing is selected as part of a combined session, the full session will take place in person.
Equipment & Setup

Online Sessions: Please confirm you have a stable internet connection and a suitable exercise/yoga mat, as equipment cannot be provided for online sessions. Spine Reform Coaching: A complimentary Spine Reform Assessment is required before starting the program so your movement can be assessed and the program tailored safely.
For online sessions, please confirm the following:
For Yoga and Deep Stretching sessions, which equipment or props do you have available?
Complimentary Spine Reform Assessment Required: A complimentary assessment must be completed before beginning Spine Reform Coaching. This helps me understand your current movement, balance, mobility, current limitations, and any relevant back pain or discomfort history so the program can be tailored appropriately to you.
For Online Spine Reform Coaching, I have access to:
For In-Person Spine Reform Coaching, I have access to the following:
For Sound Healing sessions, which setup items are available?
Goals and Experience
What would you most like help with? (select all that apply)
Previous Yoga or Movement Experience
Preferred Session Intensity
Which Sound Healing Experience(s) are you interested in? (select all that apply)
Please tell me more about your goals (optional)
Health Screening
Do you have any injuries, pain, recent surgeries, pregnancy, medical conditions, movement restrictions, or professional medical advice that may affect your participation?
Please provide any relevant details, including anything that may require modifications or additional care.
Consent and Policies
Scope of Services and Medical Responsibility
Voluntary Participation and Personal Responsibility
Health Information and Ongoing Disclosure
Acknowledgement of Risk and Liability

I voluntarily accept the ordinary risks associated with participating in these services. To the fullest extent permitted by applicable law, I agree not to hold My Mat My Playground L.L.C.-FZ or its instructors responsible for injury, loss, or damage arising from those ordinary risks, my failure to follow instructions, or my failure to disclose relevant information. This does not exclude any liability that cannot lawfully be excluded.
Contact Sound Massage Consent
Hands-On Adjustment Preference (In Person Sessions)
Booking, Payment, and Attendance Policies
Session Timing: Sessions begin and end at the agreed scheduled times. Late arrival, joining late, or stepping away during a session will not extend the scheduled end time. Additional time cannot be guaranteed due to other appointments or commitments.

Cancellations and Rescheduling: At least 24 hours’ notice is required to cancel or reschedule. Sessions cancelled or changed with less than 24 hours’ notice may be charged in full or deducted from a package, except where otherwise agreed.

Payments and Refunds: Payment is required by the stated due date. Payments, bookings, and packages are non-transferable and non-refundable once used or commenced, except where required by law or expressly agreed.

Pricing: Standard pricing excludes venue hire, exceptional travel requirements, equipment rental, and special event production costs. Bookings for 10 or more participants may be quoted individually based on the specific requirements of the booking.

Package Validity: Sessions must be used within the validity period stated at purchase. Unused sessions do not automatically roll over or receive an extension.

Online Sessions: Clients are responsible for participating from a safe, suitable space with appropriate equipment and a reliable device and internet connection. The instructor may pause or end a session if the environment or participation appears unsafe. Clients should keep a phone accessible and provide their current location if emergency assistance becomes necessary.

Instructor Cancellation: If My Mat My Playground L.L.C.-FZ must cancel, the session will be rescheduled, credited, or refunded as appropriate.
Agreement to Booking, Payment, and Attendance Policies
Privacy and Data Use

I consent to My Mat My Playground L.L.C.-FZ collecting, using, and processing the personal and health information provided in this form where reasonably necessary to assess suitability, provide services appropriately and safely, manage bookings and payments, communicate with me, maintain necessary business records, and meet applicable legal or regulatory requirements. I understand that trusted service providers may process information where necessary to support MMMP's operations and services. My personal information will not be sold or shared with third parties for their own marketing purposes.I may request access, correction or deletion, subject to applicable legal and record-keeping requirements, by using the privacy contact option available on the MMMP website.
By providing my signature, I confirm that the information provided is accurate and that I have read, understood, and agreed to the required consents and policies in this form.
Signature
Should be Empty:

New Client Registration & Health Questionnaire

Personal Details

Emergency Contact

Session Preferences

Equipment & Setup

Goals and Experience

Health Screening

Consent and Policies

Booking, Payment, and Attendance Policies