Personal information of participant (All information will be treated in the strictest confidence.)
Name *
Contact number *
Contact number
Gender *
Date of birth *
Date of birth
Of the applicant
Parent/Legal guardian details (Skip this section if the participant is over 18)
Name of parent/guardian
Name of parent/guardian
Phone number of parent/guardian
Phone number of parent/guardian
Emergency contact details
Name *
Part 1 - Your background and your health
1 - Does your work/sport involve any of the following *
2 - Will this be your first time practicing pilates *
If no, have you previously attended any of the following
Number of classes attended previously
3 - Has your doctor ever said that you have any sort of heart trouble or defect *
4 - Do you feel pain in your chest when you do physical activities *
5 - Are you or could you be pregnant right now *
6 - Have you been pregnant in the last 6 months *
7 - If you have had a baby, how was it delivered
8 - Do you often get headaches *
9 - Do you ever lose your balance because of dizziness or do you ever lose consciousness, feel faint or dizzy *
10 - Do you have high blood pressure *
11 - Is your blood pressure normal or low
12 - Have you had major surgery in the last 10 years *
13 - Have you had minor surgery in the last 2 years *
14 - Do you suffer from any of the below *
15 - Do you / have you had a terminal illness *
16 - Have you ever been told you have arthritic joints, osteoporosis, osteopenia, or any bone or joint problems that may be made worse by exercising *
17 - Do you suffer from back and/or neck pain *
18 - Do you have any pain or restricted movement in any other joints (eg. hip, knee, ankle, shoulder) *
19 - Have you ever been diagnosed with hyper-mobility (excessive joint mobility) *
20 - If you answered “yes” for any questions from 14-19, do you have medical permission to exercise
21 - Are there any movements that cause you pain *
22 - Are you taking any drugs or medication which may affect your ability to exercise *
23 - Have you ever been recommended to take up pilates by a specialist practitioner *
24 - Do you hereby give us permission to contact your specialist practitioner
If you have answered YES to any of questions 3-21 above, we advise that you consult with your medical practitioner before you start Pilates Classes.
Part 2 - Your aims
Part 3 - Important information
Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes. It is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with your teacher. It is also wise to wait six weeks after the birth before resuming exercise. Pilates exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting Pilates sessions. These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner. The teacher can accept no liability for personal injury related to participation in a session if: • Your doctor has, on health grounds, advised you against such exercise • You fail to observe instructions on safety or technique • Such injury is caused by the negligence of another participant in the class/studio. Exercise should be performed at a pace that feels comfortable for you. Pain is the body’s warning system and should not be ignored. Please inform your teacher immediately if you feel any discomfort during a session. Please also inform your teacher if you felt any discomfort after a previous session. I understand that Pilates exercises involve hands-on corrections and I hereby consent for my teachers to work in this way. I confirm that I have read and understood the above advice and that the information I have given is correct. I confirm that my teacher may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information: •will be used in confidence and stored securely •will not, under any circumstances, be shared with a third party without my written consent. • may be retained by the teacher for a period of time such as complies with professional, legal and insurance requirements that they must fulfil. I confirm agreement for my teacher to contact me with information on classes and other Pilates-related activities, and understand that I have the right to withdraw this ‘consent to be contacted’ at any time. *
Indemnity & Terms and condtions
Indemnity *
Terms & Conditions *