CLIENT FORMS

Name *

First Name

Last Name

Phone *

(###)

###

####

Previous Experience with Pilates and GYROTONIC® *

Yes

No

General Health *

Excellent

Good

Fair

Poor

Are you currently experiencing any physical problems? *

Yes

No

Are you currently receiving professional health care services (i.e. Chiropractic, Medical, Massage Therapy, Physical Therapy, etc.)? *

Yes

No

Please check any of the following that apply (past or present): *

Arthritis

Back Pain/Disc Issues

Bowel/Bladder Changes

Cancer

Circulatory Disease

Diabetes

Dizziness

Fainting Disorder

Heart Disease

High Blood Pressure

Hypoglycemia

Knee Pain/Injuries

Neck Pain/Injuries

Neuropathy

Osteoporosis

Osteopenia

Osteoarthritis

Pregnancy (currently)

Scoliosis

Seizure Disorder

Shoulder Pain/Impingement

Stenosis

Thyroid Disorder

Other

None of the above

LIABILITY RELEASE *

In consideration of being allowed to participate in any way in the Movement Revolution LLC, related events and activities, the undersigned acknowledges, appreciates and agrees that: 1. The risk of injury from activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release and hold harmless Movement Revolution LLC their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“Releasees”), with respect to all and any injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Emergency Telephone Number *

(###)

###

####

Parent/Guardian of Participant of Minority Age (Under age 18 at time of registration)

This is to certify that I, as parent/guardian with legal responsibility for the participant do consent and agree to his/her release, as provided above, of al the Releasees, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, even if arising from their negligence, to the fullest extent permitted by law.

I AGREE

STUDIO POLICIES *

I have read the following policies of Movement Revolution LLC and agree to comply: The studio has a 24 hour cancellation policy. Appointments must be cancelled at least 24 hours prior to the scheduled appointment time to avoid the full lesson charge. For illness, please call by 8:00 a.m. the same day of the appointment to avoid a full lesson charge. For group classes, payments are made for 4 sessions at a time ($140), can be used for any MR class within the expiration time of 2 months from the 1st session. Payments made for services, both present and future, are not refundable and are due on the first lesson. For private sessions, there is a 4 month expiration on 10x packages and a 2 month expiration on 5x packages.

I AGREE