Pilates of Charlotte

New Client Form

All new clients are required to fill out the forms below for General Information, Emergency Contact, Medical History and Agreement & Release.

GENERAL INFORMATION

Name

Address

City

State

Zipcode

Email

Cell Phone

Home Phone

Birthday

Height
ft in
How did you hear about us?
If referred, whom can we thank?
Do you have any experience with Pilates, Yoga, TRX or Barre? Y / N
If yes, how long and with whom have you been training?

Do you exercise regularly? Y / N
If yes, which forms of exercise and how often?

What are your goals? What do you want from this program?

Are you interested in finding out more about...?



EMERGENCY CONTACT

Name

Relationship

Home Phone

Cell Phone

Work Phone

MEDICAL HISTORY

If you have any kind of pre-existing injuries or conditions that may affect or limit your ability to exercise or to participate in training, we ask that you let us know and that you consult a health care practitioner to approve your participation.

Have you had any broken bones or undergone surgery? Y / N
If yes, please explain:

Do you have or have you had any of the following conditions?



















Are you currently?



Do you have any injuries or physical conditions that limit your ability to exercise? Y / N
If yes, please explain:

AGREEMENT & RELEASE

1. In consideration of being allowed to participate in the activities and programs of Pilates of Charlotte and to use its facilities, equipment and machinery in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge its directors, officers, agents, employees, representatives, successors and assigns, administrators, executors, and all others from any and all responsibilities or liability from injuries or damages resulting from my mentioned activities. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of Pilates of Charlotte or the use of any equipment at Pilates of Charlotte.

2. I understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment are a potentially hazardous activity. I also understand that fitness activities involve the risk of injury and even death, and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I understand this program does not provide any form of medical treatment, nor are its fitness professionals, licensed medical practitioners. I hereby agree to expressly assume and accept any and all risks of injury or death.

3. I also understand and agree to Pilate of Charlotte's business policy regarding refunds, credits and class expirations. No refunds, exchanges only as studio credit. Classes expire 3/6 months, respectively, from the date of purchase. Requests to extend the expiration of classes will be honored for medical conditions only.

4. We have a 24 hour cancellation policy. You will be charged the full amount if you do not give a 24 hour notice, regardless of the cause of the need to cancel your class or appointment. We appreciate your understanding.

Sign above

Date
If known, who will you be training with?