Pilates Practice at the Studio

CONSENT FORM

Health Questionnaire & Consent Form
Please fill out the following health declaration and waiver form in order to participate in our Pilates Classes
Have you done Pilates before?
Do you have any health or medical problems? (E.g., Heart issues, asthma, high blood pressure)
Do you have any current pain or injuries/conditions that may affect your movements in any way?
Do you have any past injuries/conditions that may affect your movements in any way?
Are you currently pregnant or have you recently given birth in the last 6 months?
Have you had any recent surgeries that we should know about?
Are you on any regular medication that we should know about, or which may affect your ability to exercise?
Unless otherwise listed above, are you physically active, able & willing to participate in Pilates classes?
Waiver of Liability and Prospective Release Form for Pilates with Katrina

 

I declare that I am over 18 years of age (or have otherwise provided parental consent) and acknowledge and understand that I have voluntarily chosen to participate in the classes and activities offered by Pilates with Katrina. I understand the nature of the Pilates with Katrina’s fitness activities and am qualified, willing and able to participate in such activities.

I acknowledge and agree that the workouts are a recreational sports activity and may involve strenuous physical activity including, but not limited to stretches, lifts, use of props, gymnastic movements, strenuous bodyweight exercises and other strenuous activities that I am not obliged to perform, nor am I obliged to participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during classes.

I understand that there are inherent risks in all aspects of physical exercise, and I acknowledge that I have been informed of the possible strenuous nature of training. I agree that prior to my participation I will inform Pilates with Katrina of any known medical conditions or factors that may place me at risk. Pilates with Katrina may request a medical release from my medical practitioner prior to participation. I will inform Pilates with Katrina of any symptoms before, during and after participation in a Pilates with Katrina class. I also understand that if I am a prenatal or postnatal client, that I must consult with my physician and receive clearance to perform physical exercise.

I acknowledge that Katrina Kazim is a qualified pilates instructor certified by Studio Pilates, however, does not hold a current Certificate III or IV in Fitness or a personal trainer qualification.

I fully accept and assume all such risks associated with Pilates with Katrina and release Pilates with Katrina and its staff from any and all liability for any loss, damage, injury or expense that I may suffer, or that my next of kin may suffer as a result of my participation in the classes, activities and services provided by Pilates with Katrina. I agree to hold harmless and indemnify Pilates with Katrina and its employees and agents from any and all liability for any damage to the property of, or personal injury to, any third party, resulting from my participation in any program, activity or service provided by Pilates with Katrina. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full force and effect.

I declare that I have advised Pilates with Katrina of any injury, back, neck or joint pain, restricted movement, heart issues, asthma, or high or low blood pressure, arthritis, slipped or bulging vertebral disk, pelvic floor conditions, dizziness, diabetes, epilepsy, hernia, bone degeneration, high cholesterol, allergies or chronic illness. I also declare that I have notified Pilates with Katrina if I am pregnant and/or have given birth in the last 12 months, or if I have undergone surgery in the past 12 months.

Pilates with Katrina shall not undertake any obligation (whether contractually, at common law or otherwise) to advise or treat me in relation to any of the matters referred to in the preceding paragraph. I acknowledge that it is my obligation and mine alone to take responsibility for my health and wellbeing during any type of exercise I undertake with Pilates with Katrina. I give consent to certain physical corrections/touching that may be necessary to ensure proper technique and body alignment.

I acknowledge that Pilates with Katrina shall not be liable or responsible to me for articles lost, damaged or stolen from any of its venues.

I understand that from time-to-time Pilates with Katrina and/or its employees or contractors may film or photograph the classes, activities or services provided by Pilates with Katrina. I permit Pilates with Katrina and its licensees or assignees to use, publish, reproduce, distribute, create derivative works of, perform, display and/or otherwise exploit my name, image, voice and likeness, either complete or in part, alone or in conjunction with any wording, for uses including publicity and/or merchandising and/or editorial purposes in any country in connection with any part of the business of Pilates with Katrina in any manner and in all forms of media whether now existing or developed in the future. I hereby waive any right to inspect and approve the photographs or videos or the printed/digital/electronic matter that may be used in conjunction with them now or in the future, regardless of whether that use is known or unknown. I waive any right to copyright or royalties or other compensation from or related to use of the photography or videos or adaptations thereof.

The terms and conditions of this release form and waiver of liability are subject to change without notice.

All persons under 18 years of age must have this form signed on their behalf by a parent or guardian before attending a Pilates with Katrina class. Once the parent or guardian has signed the waiver, persons under 18 years of age may attend Pilates with Katrina classes.

 

I,                                                                                                                , acknowledge that I have read the above release and waiver of liability and fully understand its contents. I agree to the above waiver and confirm all the information provided by or on behalf of myself is true and correct and that I have provided Pilates with Katrina all necessary information about my health that may restrict my ability to perform a class. I agree that my body is my responsibility, and I will let my instructor know if I experience any pain or discomfort during the class. I acknowledge that if the instructor feels that I am unfit to participate in the workout, they will request I discontinue the workout.

Thanks for submitting! We will be in touch if we have any questions about your form details.

If, for some reason you are unable to submit the above electronic form, you can download a PDF version below.

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