Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Sex *

Male

Female

Do you have any experience with Pilates?

YES

NO

Do you exercise regularly? *

YES

NO

Are you presently on any medication? *

YES

NO

Do you have any allergies?

YES

NO

Do you have any dietary requirements? preferences e.g. paleo, vegan, low fodmap etc

YES

NO

Have you had any broken bones or undergone any surgery in the last 5 years? *

YES

NO

Do you suffer from any of the following conditions?

Scoliosis

Joint Replacement

Spinal Disc Issues

Sciatica

Asthma

Migraine/Headaches

Chronic Illness

Heart Condition

Other

Are you currently seeing a Health Care Practitioner for any of the above conditions?

YES

NO

Has approval been obtained to participate in Pilates?

YES

NO

I understand that I am participating in Pilates classes, offered by Kirsti Pilates To you, during which I will receive information and instruction about movement and health either through face to face teaching or virtual teaching via the appropriate software platform. I understand that the practice of Pilates involves physical exertion that may be strenuous and may cause injury and I am fully aware of the hazards involved. Because physical exercise can be strenuous and subject to risk of serious injury, Kirsti Pilates To You urges you to obtain a physical examination from a doctor before participating in any Pilates sessions.

I agree that by participating in physical exercise or training activities, I am doing so entirely at my own risk. I acknowledge that it is my responsibility to inform the instructor when I begin a class of any injury or other condition that might affect my ability to participate and to inform the instructor at each class I attend.

In consideration of being permitted to participate in Pilates sessions offered by Kirsti Pilates To You, I agree to assume the full responsibility for any risks, injuries or damages, known or unknown, that I may incur as a result of participating in these sessions. I knowingly, voluntarily and expressly waive any claim I may have against Kirsti Pilates To You for injury or damages that I may sustain as a result of participating in the sessions. I, my heirs and legal representatives forever release, waive, discharge and covenant not to bring legal action against Kirsti Pilates to You for any personal injury, damage or death caused by negligence or other acts. To the extent that statute or case law does not prohibit releases for negligence, this release also covers and includes negligence and any legal theory based upon negligence. If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid and/or unenforceable, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.

By checking the box below and submitting this form, I acknowledge that I understand the content and that this release cannot be modified orally. I am aware of all of the consequences that can occur and I still chose to go ahead.

I understand that 24 hours’ notice of cancellation of bookings must be given or a full fee will be charged.

I understand that all information provided by Emma Lynas is general in nature and may not take into considering my specific health condition or requirements. I understand that all dietary and lifestyle suggestions made by Emma should be discussed with my primary healthcare physician before commencing.

*

I agree to the terms & conditions of this waiver