Health Form - Laison Pilates

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Home
About Us
Services and Pricing
Health Form
Contact us
Terms & Conditions

Name *

Surname *

Email Address *

Phone *

Date of birth *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Emergency Contact Name *

Emergency Contact Phone *

Have you done Pilates before? *YesNo

If yes, at what level?BeginnerIntermediateAdvanced

How would you describe your lifestyle? *Very ActiveModerately ActiveNot Active

Do you participate in any other sport? *YesNo

If yes, please specify

Do you suffer from any of the following ailments? (Please select all that apply.) *AsthmaHeart IssuesReferred PainHigh/low Blood PressureHigh CholesterolHypertensionOsteoporosisArthritisEpilepsy, dizziness, migrainesHip/knee replacementI do not suffer from any of these ailments

If yes, please provide details below and check with your doctor that you are fit to exercise.

Have you recently had surgery? *YesNo

If yes, please provide details, together with clearance from your doctor that it is safe to do Pilates

Are you pregnant or recently had a baby? *YesNo

Do you have any joint issues? (back, shoulder, knee, hip, wrist, ankle, neck) *YesNo

If yes, please provide details. If you are seeing a therapist, please provide information on movements you need to avoid, together with the name and contact details of your therapist.

If there are any other health issues or medical conditions of which we should be aware, please provide details below

Consent

BY SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. PLEASE READ CAREFULLY.

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND ASSUMPTION OF RISKS

I hereby agree to the following:

That I am participating in Pilates classes offered by Celeste Marelich and their staff or apprentices, during which I will receive information and instruction about Pilates, health and wellbeing. I recognise that Pilates requires physical exertion which may be strenuous and may cause physical injury and I am fully aware of the risks and hazards involved.
I understand that it is my responsibility to consult with a physician prior to and regarding my participation in Pilates. I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in Pilates classes, courses, Programmes or Workshops.
ASSUMPTION OF RISK: In consideration of being permitted to participate, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which might occur as a result of participation, INCLUDING THE RISK OF NEGLIGENCE ON THE PART OF THE RELEASEES.
WAIVER OF CLAIMS: I knowingly, voluntarily and expressly waive any claim I may have against Celeste Marelich, their staff or apprentices, for injury or damages that I may sustain as a result of participation, INCLUDING CLAIMS ARISING FROM THEIR OWN NEGLIGENCE or breach of any statutory or other duty of care.
RELEASE: I, my heirs or legal representatives, forever release, waive, discharge and covenant not to sue Celeste Marelich, their staff or apprentices, for any injury or death CAUSED BY THEIR NEGLIGENCE, breach of contract, or any other acts.

By selecting YES, I confirm that I have read and agree to the above release and waiver of liability and understand its contents. *Yes, I agreeNo, I do not agree

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