Health Waiver | My Pilates Club

First name

Last name

Email

Phone

Emergency contact details

Date of birth

Occupation

Sports and hobbies

Do you have any heart problems?

Yes

No

Do you have asthma?

Yes

No

Do you have epilepsy?

Yes

No

Have you had surgery in the last 5 years?

Yes

No

If yes, please explain the surgery.

Are you pregnant?

Yes

No

Do you have any injuries or pain?

Yes

No

If yes, please specify what injuries or pain.

Any other details we need to know?

I ACCEPT FULL RESPONSIBILITY FOR ATTENDING PILATES; I CHOOSE TO DO SO AT MY OWN RISK. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM MY INSTRUCTOR SHOULD ANY OF MY MEDICAL DETAILS CHANGE.

Your signature

PLEASE NOTE

ALL PILATES CLASSES ARE CARRIED OUT BY A QUALIFIED PILATES TEACHER. PLEASE ADVISE THE INSTRUCTOR BEFORE COMMENCING A CLASS OR 1 TO 1 IF YOUR ABILITY TO EXERCISE HAS CHANGED. PILATES EXERCISES ARE SAFE BUT, AS WITH ALL FORMS OF PHYSICAL EXERCISE, IT IS PRUDENT TO CONSULT A DOCTOR BEFORE STARTING CLASSES IF YOU HAVE ANY MEDICAL CONDITIONS OR INJURIES. IF YOU HAVE ANY DOUBTS ABOUT THE SUITABILITY OF THE EXERCISES YOU SHOULD REFER BACK TO YOUR MEDICAL PRACTITIONER.

COMPLETE YOUR HEALTH WAIVER