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First Name

Last Name

Date of Birth

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Do you have a doctor’s permit to participate in physical activities?

Yes

Please specify any health issues or diagnoses past or present. Please indicate if you have taken a reformer pilates class previously and how long you have practiced.

Initials or Parent Guardian Initials

I declare that the info I’ve provided is accurate & complete

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

*I agree that by entering my contact information that I am opting in to communication from Aplomb Pilates

I agree to the Full Waiver of Release and Liability Below

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Full Waiver of Release and liability

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