Name
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First Name
Last Name
Mobile Phone
*
Country
(###)
###
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Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Contact Times
*
Can you be contacted:
Gender
*
Gender
Follow Up
*
May I follow up after your sessions to see how you enjoyed your experience here at Contrology Room? *
Follow Up Contrology Room Info
*
May I send you information about Contrology Room events and specials? *
Birtdhay
*
Date of Birth
MM
DD
YYYY
Health History
*
Do you have (or have you experienced) any of the following conditions?:
Health Details
Please, specify details:
Medications
*
Are you taking any medications for any of the above? (please, list)
Pregnancy
*
Are you pregnant?
Smoke
*
Are you a regular smoker?
Diet
*
Do you adhere to a consistent diet?
Exercise
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Do you stretch, meditate and/or exercise regularly?
Exercise Type
*
If yes, please indicate type and frequency:
Previous Pilates
*
Have you had any previous Pilates experience?
Previous Pilates Where
*
If yes, where please, and for how long?
Goals
*
What do you hope to achieve from Contrology Room? (i.e. what are your fitness goals)
Doctor's Phone
*
Doctor's Phone:
Country
(###)
###
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Emergency Phone
*
Emergency Phone Number
Country
(###)
###
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Consent
*
INFORMED CONSENT AND WAIVER & RELEASE OF LIABILITY
I have volunteered to participate in a program of progressive physical exercise and to retain the services of Contrology Room, to receive physical training. I intend to assume all risk of injury from my participation. To that end, I acknowledge and agree to the following:
MEDICAL
a) The muscle and cardiovascular conditioning program at Contrology Room utilizes Pilates, cardio circuitry, stretching and strengthening. During and after exercise, there exists a potential for muscle soreness and stiffness, abnormal blood pressure, fainting, disorders of the heart beat, and instances of heart attack and death. I assume all of the foregoing risks and accept personal responsibility for any other damages or other injury I might suffer.
b) I know that I have the right to choose what exercises I do or do not perform in addition to withdrawing from any exercise at any time.
c) I understand that a physician’s examination and approval should be obtained prior to participation in any exercise program. I understand that Contrology Room has the right to request a doctor’s letter at any time during the program where it is deemed necessary, by instructor or owner, to have approval before continuing. Contrology Room may cancel any appointments scheduled until said letter has been received.
d) I hereby fully and forever release, discharge and hold harmless Contrology Room, its agents, officers and directors from any and all liability to me, my heirs and next of kin, for any and all claims, demands, rights of action, causes of action, losses or damages on account of injury including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of Contrology Room, its agents, partners or employees or its released “Releases” enumerated above or otherwise, and I hereby waive any right to sue any of the foregoing for any injuries I may sustain or losses I may incur whether known or unknown resulting from the activity described above.
e) I recognize that my participation in the activity covered hereby is conditioned upon my signing and returning this waiver and release. I understand that I may show this Informed Consent and Waiver& Release of Liability to, and consult with, my own independent legal counsel before signing.
f) Contrology Room, has not made any representation as to the nature and quality of the facilities of equipment to be used or as to any other matter related to my participation in the forgoing activity. I understand that the “Releases” enumerated above or otherwise owe no duty or obligation to me.
I have read and understood this Informed Consent and Waiver & Release of Liability and it accurately sets forth my intentions and I agree to bound by its provisions.
Consent Date
*
Please enter today's date of your agreement.
MM
DD
YYYY
