Active Pilates Waiver

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Name *

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Last

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Phone *

Date of Birth *

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Emergency Contact *

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Emergency Contact Phone *

Health History

Regular exercise is associated with many health benefits, yet any change of activity may increase the risk of injury. Completion of this questionnaire is a first step when planning to increase the amount or type of physical activity in your life.

Please answer the following questions to the best of your knowledge.

Has as a physician ever diagnosed you with a heart condition and/or limited your physical activity? *

Yes
No

Have you ever felt pain in your heart or chest? *

Yes
No

Have you ever lost consciousness or lost your balance because of dizziness? *

Yes
No

Do you have a joint or bone problem (such as arthritis) that may be aggravated by a change in your physical activity? *

Yes
No

Is a physician currently prescribing medication for blood pressure or a heart condition? *

Yes
No

Are you pregnant? *

Yes
No

Do you have insulin-dependent diabetes? *

Yes
No

Do you know of any other reason why you should not exercise or increase your level of physical activity? *

Yes
No

If you answered “YES” to any of the questions above, please talk with your doctor BEFORE you become more physically active. If you'd like to explain why you answered yes do so below. *

Please list any orthopedic issues or previous surgeries that you have had that affect your daily activity?

Liability Waiver

Because physical exercise can be strenuous and subject to risk of serious injury, we urge you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity.

You agree that by participating in physical exercise or training activities, you do so entirely at your own risk.
You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death. We are also not responsible for any loss of your personal property. You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a release of liability.

You expressly agree to release and discharge the trainer or instructor from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer or instructor for personal injury or property damage.

To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence. If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.

By signing my name below I acknowledge that I understand its content and that this release cannot be modified orally. *

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