A Pilates House Registration Form

First Name
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Last Name
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Date
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Address
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City
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State
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Zip
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Mobile phone
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Home
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Work
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Email
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Date of Birth
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Age
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Gender
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How did you hear about us?
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Why do you want to do Pilates?
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Do you have any condition(s) that may prevent you from participating in Pilates?
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Do you have pain or discomfort anywhere in your body?
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Are you pregnant?
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If so, due date?
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Number of prior deliveries
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Prior injuries and dates of occurrence
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Prior surgeries and dates of surgery
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Please list current medications you take:
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What types of activities do you participate in regularly?
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Emergency contact:

Name
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Relationship
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Phone
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Please list your personal Pilates equipment (house calls only)
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A Pilates House Waiver

I am participating in Pilates, exercise classes, health programs and/or workshops offered by A Pilates House or Cara Friedman during which I will receive information and/or instruction about Pilates, fitness and health. I recognize Pilates and exercise require physical exertion which may be strenuous and may cause physical injury, and I am fully aware of the hazards involved;

There are risks and dangers inherent in using the equipment relating to any Pilates or Pilates class, exercise class, health program, client owned equipment, or workshop offered by A Pilates House or Cara Friedman. I am aware that the use of equipment can be hazardous and as such, I agree that I will not adjust, alter or change any settings to equipment while participating in any Pilates Session, exercise class, health program or workshop, without instruction;

It is my responsibility to consult with a physician prior to and regarding my participation in any Pilates, exercise class, health program or workshop. I represent and warrant that I am physically fit and I have no medical conditions, which would prevent my full participation in Pilates sessions, exercise classes, health programs or workshops;

In consideration of being permitted to participate in Pilates, exercise classes, health programs or workshops, I knowingly voluntarily and expressly waive any claim of liability or negligence and shall not hold A Pilates House or Cara Friedman, its officers, agents, shareholders, employees and independent contractors liable for personal/bodily injury or damages which occur to me for any loss of or injury to my person or property. This waiver includes, but is not limited to, any loss, damage or destruction of my personal property and is intended to be a complete release of any responsibility for personal injuries and/or property loss/damage sustained by me while on A Pilates House premises, whether using exercise equipment or not; and

I, my heirs and/or legal representatives forever release, waive, discharge and covenant not to make a claim against or sue A Pilates House, Cara Friedman, its officers, agents, shareholders, employees and independent contractors for any injury or death caused by negligence or other acts.

I hereby confirm that I am able to participate in a physical exercise program. I understand that there is a risk of injury from activities involved in this program, including the potential for permanent paralysis and death, and while particular rules and personal discipline may reduce this risk, I knowingly and freely assume all risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation. 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.

I agree that I, my heirs, personal representatives and next of kin, legal representatives and assigns will not make claims against A Pilates House or Cara Friedman for any injury or damage resulting from my participation in Pilates sessions with Cara Friedman. I have carefully read this agreement and release of liability and fully understand its contents. I am aware that this is a release of liability and a contract between myself and A Pilates House or Cara Friedman, and sign it of my own free will.

Client’s health warranty: Client and/or Buyer each represent that Client is in good health and has no disability, impairment, injury, disease or ailment preventing him/her from engaging in active or passive exercise or which would cause increased risk or injury or adverse health consequences as a result of use of A Pilates House or Cara Friedman.

Independent Contractors: From time to time we may make available to members and their guests the services of independent contractors. We do not warrant or guarantee the quality of these services and do not guarantee that these services will remain available to Members or their guests for any period of time, and hereby disclaim all liability arising out of such services.

Waiver of Liability: Client assumes full responsibility for his or her use of the facility and releases of A Pilates House or Cara Friedman from any and all claims, including those caused in whole or in part, by the negligence of A Pilates House or Cara Friedman and shall indemnify A Pilates House, Cara Friedman or the owner of the location of A Pilates House the client is utilizing, its affiliates, agents and employees against any and all liability arising out of use of facilities.

Please check here to submit the form !

Please check here to submit the form !

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